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SPRING 2006 



ust how perilous is pride? 

s lust really so lethal? Does 
greed lead straight to the 
grave? Doctors, sworn to protect life, fine 
themselves examining their own transgressions. 

\ --5 




A nurse steadied the progre 
of her young patient as the 
strolled the corridor of < 
infant and toddler floor of 
Children's Hospital Boston a 
half century ago. The Harvard- 
affiliated hospital began 
in 1 869 in the honne of an 
alumnus, Francis Henry 
Brown, Class of 1 861 . 



SPRING 2006 • \OLUME 79, NUMBER 4 

rONT F. 



Pulse 4 

Match Day 2006; celebrations of HMS 

past, present, and future 

President's Report 7 

b\ Steven A. Scbwcdcr 

I Bookshelf 8 

! Bookmark 9 

I A review by Elissa Ely of The Denial 

= of Aging: Perpetual Youth. Eternal Life, and 
Other Dangerous Fantasies 

1 Benchmarks 1 

^ Our brains at Macy's; those eternal 

g internal clocks; the worth of a weight 

s of gold; and other research lindings 

8 Class Notes 58 

o obituaries 61 


z The Eighth Deodly Sin 64 

2 Surely medical sins don't stop at seven; 
£ physicians ponder other fatal flaws. 

Cover photograph: Louie Psihoyos/Getty Images 


Introduction: The Seven Deadly Sins 14 

PRIDE: Vanity Fare 16 

why do so many doctor jokes Couch on the sin of pride? bv p e r r i k l a s s 

ENVY: I'll Have What She's Having 20 

Curing em-y may be as simple as rcfocusing your lens, by elissa e l y 

GREED: The Sin of Wages 24 

why do the good doctors on television hospital dramas drive old cars 
while the bad ones wear bespoke suits? by atul gawande 

WRMH: All the Rage 28 

when is anger good for you — and for medicine? by alice flaherty 

SLOTH: American Idle 32 

Sometimes slacking off can be the best medicine of all. by r a f a e l c a m p o 

GLUnONY: Gorged on Guilt 36 

The waistline wars pit \irtue against vice while ignoring the objections 
of science and logic. bywiLLiAM ira bennett 

LUST: Lust Me, I'm a Doctor 40 

Passion marks the times in a physician's life — and adds life to his times. 



Creature Comforts 44 

clinicians soothed the ills of the savage — and not so savage — beast during 
the short Ufe of the Harvard School of Veterinary Medicine. 

|i V A N T H O N Y S . P A T T O N 

The Soul of a Doctor 52 

Har\'ard Medical School students explore what it means to become a physician. 

Harvard Medical 


U L L E T I N 

In This Issue 


deadly sins. To modern eyes, his "sins" may seem a little odd, as they 
generally don't entail doing anything bad or, indeed, doing much of 
anything at all. Thus, a contemporary secular reader might be inclined to trans- 
late the word as "criterion" rather than "sin," because Gregory's syndrome of 
pride, envy, greed, wrath, sloth, gluttony, and lust could well be seen as a 
precursor of the so-called Axis II disorders of contemporary psychiatry: the 
dramatic, self- centered, and impulsive conditions known as histrionic, narcis- 
sistic, and antisocial. Alternatively, his list can be seen as comprising the pit- 
falls of character that each of us must wrestle 
from day to day. 
Modern medicine, especially pre- 
ventive medicine, is at least as pre- 
occupied with these deadly sins as 
were the Fathers of the Church. It 
is not possible to read the New 
York Times on Tuesdays without 
finding warnings of some aspect 
of sloth or gluttony and its 
implications for life expectancy, 
not eternal life. Lust and its conse- 
quences, happy or horrifying, are ever- 
present in the examining room. Therapists 
hear about envy, pride, or WTath, one way or 
another, in every session. And whenever Medicare or managed care issues a new 
fee schedule, the implication that physicians' greed is, at bottom, the problem 
with the health-care system bubbles again to the journalistic surface. 

So, in this issue seven Bulletin contributors face up to Gregory's sins, one by 
one, if not in an effort to shrive themselves, then to try to come clean on the 
operation of these various states of mind in their lives and those of their 
patients. We trust that our readers will find this exercise consoling. 

Uj\^^\ (aA ^lA^y-jit 


William ira Bennett '68 


Paula Brewer Byron 


Ann Marie Menting 


Janice O'Leary 


Elissa Ely '88 


JudyAnn Bigby 78 

Rafael Campo '92 

Elissa Ely '88 

Daniel D. Federman '53 

Timothy G. Ferris '92 

Alice Flaherty '94 

Atul Gawande '94 

Robert M. Goldw-jm '56 

Petri Klass '86 

X'ictoria McEvoy '75 

James J. O'ConneU '82 

Nancy E. Oriol '79 

Anthony S. Patten '58 

Mitchell T. Rabkin '55 

Jason Sanders '08 

Eleanor Shore '55 


Laura McFadden 


Steven A. Schroeder '64, president 

A. W. Karchmer '54, president-elect 1 

William W. Chin '72, president-elect 2 

Susan M. Okie '78, vice president 

Rodney J. Taylor '95, secretar)' 
Kathleen E. Toomey '78, treasurer 


Wesley A. Curry "76 

Timothy G. Ferris '92 

Gerald S. Foster '51 

Edward D. Harris, Jr. '62 

Linda S. Hotchkiss '78 

Lisa I. lezzoni '84 

Katherine A. Keeley '94 

Christopher J. O'Dormell '87 

Rachel G. Rosovsky '00 


George E. Thibault '69 


Harold J. Bursztajn '76 
Joseph K. Hurd, Jr. '64 

The Harvard Medical Alumni BuUctin is 

published quarterly at 25 Shattuck Street, 

Boston, MA 02115 " by the Harvard 

Medical Alumni Association. 

Phone: (617) 384 8900 • Fax: (617) 384 8901 

Email: bulletin(s'' 

Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191-7757 • Printed in the U.S.A. 





■'Forty-five million people are 
uninsured and, as Rushika 
Fernandopulle '94 wrote, gaps 
in health insurance have created 
a new 'caste of the ill, infirm, 
and marginally employed.'" 

Moral Danger 

I want to commend you tor addressing 
the critically important issue of univer 
sal health coverage in the Autumn 
2005 issue of the Bulletin. As one of the 
richest countries in the world, the 
United States spends more per capita 
on health than other countries and 
achieves poorer outcomes. Forty-five 
million people arc uninsured and, as 
Rushika Fernandopulle "94 wrote, gaps 
in health insurance have created a new 
"caste of the ill, infirm, and marginally 
employed." To be sure, it is a moral as 
well as an economic issue. 

Modern medical science may pro\ide 
us with more beneficial diagnostic and 
treatment options than our society can 
afford. W'e may not be able to do every- 
thing for everyone, and we may be forced 
to make difficult, sometimes tragic 
choices among competmg health needs. 
These are not purely medical choices; 
they are ethical ones best made by all of 
us struggling toward consensus. 

I have sent the BiiUctins autumn issue 
to my daughter, a family practitioner in 
rural northern California who operates a 
mobile medical practice to provide care 
to the underser\-ed. (In 2003, the Califor- 
nia Medical Association recognized her 
as the best rural practitioner in the 
state.) She has long been a strong advo- 
cate for a single-payer system and wtU 
find this issue of the Bulletin helpful to her 
advocacy efforts. She will also find the 
Katrina article of great interest. After 

the storm, she took one of her mobile 
units to Texas to provide care for hum 
cane \ictims. 



A Turn for the Worse 

I found the special report in the Autumn 
2005 issue of the Bulletin intriguing, 
amusing, and somewhat misleading. 

I belie\"e federalized health care is poHt- 
ically ine\-itable. However, those who pro- 
pose and support this approach should be 
those who have experienced this type of 
system. In the United States that appUes 
only to those vv'hose sole health insurance 
is Medicare with no supplements. 

The reality is that the semantics are all 
wrong. No nation in the world has a sys- 
tem of "health care." The systems are all 
intended to provide "sickness care." Since 
the real game is sickness care, the costs 
will always be open ended. As the tech 
nologies of medical care expand, the costs 
will increase, and as the population ages, 
the costs will grow further. The only real 
control on costs in the sickness industry 
is some form of rationing. The labels used 
don't matter, whether they are "experi- 
mental," "not covered in this plan," or 
"not supported by cost-benefit outcome 
analyses." The labels are limited only by 
the imaginations of plan designers. 

Rationing will lead to dissatisfaction, 
which will increase political pressure. 

Some benefits will be extended, and a 
two-tiered system — much like the one in 
England — will develop. 

As a retired physician, I am covered 
by Medicare. To my amazement and 
chagrin, one practitioner dismissed me 
because of my coverage. I find that get- 
ting care in an appropriate timeframe 
based on my own up-to-date clinical 
knowledge is nearly impossible. 

The only hope of real preventive 
control of medical costs is the implemen- 
tation of true "health care" with its 
teaching of how to get and stay healthy. 
Teaching true health care and then 
rewarding such a lifest}ie in a manner that 
motivates is the only hope of reducing the 
costs of medical care. Why no one speaks 
to that as a solution I cannot understand! 

I agree that federalized medical cover- 
age will occur, but I don't believe those 
covered by that .system will like it after the 
first five years. If I were stUl in practice I 
would try to get the federal government 
to cover my malpractice since those costs 
will remain high and my income would fall 
under a federahzed medical care system. 

If any readers are interested, an article 
I have written exploring these issues 
in greater detail can be found at www., 


A Call to Action 

Congratulations on another excellent 
issue of the Bulletin. The superb articles 
on health- care coverage in the Autumn 
2005 issue will serve, I hope, as a catalyst 
for physician action to help improve our 
nation's health care — not an easy goal. 


The Bulletin welcomes letters to the editor. 
Please send letters hy mail (Harvard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02115); fax (6J7-384-890J); or 
email (bulletin&hms.haiyard.cdu). Letters may 
be edited for length or clarity. 



The Envelope, Please 


undertake their residencies. Almost half of the students v,t11 remain in Massachusetts, 
with another 17 percent heading to California and 9 percent to New York. Forty-six 
percent of the residen- 
cies wtU be in primary 
care, most of which are 
in internal medicine. 
The second most popu- 
lar residency Vi'as pedi- 
atrics, which 11 percent 
of the graduates will be 
entering. Compared to 
last year's fourth-years, 
emergency medicine, 
family practice, and 
general surgery all saw 
decreases in the number 
of residencies while radi- 
ation oncology and urol- 
ogy saw increases. 


Joyce Hairston 

Stanford Uriiversity Programs 

Tyken Hsieh 

University of California- 
Son Francisco 

Thomas Kozhimonnit 

Brighom and Women's Hospital 

Jennifer Sondmeyer 

Massachusetts General Hospital 


Arlo Miller 

Mayo Graduate School of 
Medicine, Rochester, Minnesota 

Korlo Munoz 

Stanford University Programs 

David Reid 

Northwestern McGaw, Chicago 

Katherine Szyfelbein 

Boston University Medical Center 

Jane Unaeze 

Einstein/Jacobi Medical Center, 
Bronx, New York 


Rachel Alt 

New York University 
School of Medicine 

Omar Amr 

University of California- 
Irvine Medical Center 

Medell Briggs 

Harbor-UCLA, Medical Center 

Maura Kennedy 

Beth Israel Deaconess 
Medical Center 

Nicholas Lopez 

Stanford University Programs 

Arabinda Pani 

Harbor-UCLA Medical Center 

Rachelle Pierre 

University Hospital, Cincinnati 

Casey Zuckerman 

Moine Medical Center, Portland 


Tarayn Grizzard 

Middlesex Hospital, Middletown, 

Jonathan Shaw 

Oregon Health and Science 
University, Portland 


Sophia Altin 

Yale-New Haven Hospital 

Monique Anderson 

Vonderbilt University Medical 
Center, Nashville 

Na^al Ativan 

Stanford University Programs 

Bobak Azamian 

Brighom ond Women's Hospital 

Herman Doucet 

University of Wisconsin Hospital 

and Clinics-Madison 

David Dudzinski 

MiossacnusetTs General Hospital 

Kelly Epps 

Johns Hopkins Hospital 

Joseph Garland 

Massachusetts General Hospitol 

Yonatan Grad 

Brighom and Women s Hospital 

Elizabeth Guancial 

I'v'assoc-i^sens General Hospital 

Vivek Iyer 

New York Presbyterian 


Janice Jin 

Beth Israel Deaconess 
Medical Center 

Kerunne Ketlogetswe 

5' 9^0"" 3-0 v'vorriens Hospital 

Gio Landry 

Johns Hopkins Hospital 

Richard Lin 

University of Chicago Hospital 

Irino Linetskaya 

Einstein/Montefiore AAedicol 
Center, Bronx, New York 

Wai-Kit Lo 

Massachusetts General Hospital 

Nicole Martin 

V'ossachusetts General Hospital 

Abigail May 

Massachusetts General Hospital 

Nupur Mehta 

Br gham o^d Women's Hospital 

Yvonne Njoge 

Hospital or tne university of 
Pennsylvania, Philadelpfiio 

Eric Osborn 

Beth Israel Deaconess 
Medical Center 

Michael Pacold 

Massachusetts General Hospital 

Molly Perencevich 

B'lgnorr, or-a .'iC^.e^s Hospital 

Joshua Rempeli 

Massachusetts General Hospital 

Martin Schoen 

Naval Medico! Center, Son Diego 

Ravi Shah 

,\AGssQC'^userTs General Hospital 

Philip Skelding 

Tulone University School of Medicine 

Selin Somersan 

New York Presbyterian 

Margaret Soper 

UCLA Medical Center 

Neo Tapela 

Brighom and Women's Hospital 


Patricia Tung 

Brigharn and Women's Hospital 

Jose Vargas 

Johns HopMns Hospital 

Nancy Wei 

Massachusetts General Hospital 

Banny Wong 

Mayo Graduate School of 
Medicine Rochester, Minnesota 

Emily Wong 

University of California- 
San Francisco 

Rachel Yung 

Beth Israel Deaconess 
AAedical Center 


Maya Balakrishnan 

Yaie-New Ho, 'en Hospital 

Leonie Heyworth 

Brigharn and Women's Hospital 

Michael Hochman 

Cambridge Hospito 

Aaron Mann 

Briqham and Women's Hospital 

Ning Tang 

Massachusetts General Hospital 

Jane Unaeze 

Yale-New Haven Hospital 

Nirav Vakharia 

Bngha"^ and Women's Hospital 

Michael Westerhaus 

Brignarri atio v'vorneris Hospital 


Thomas Deuel 

Harvard Medical School/ 
Massachusetts General Hospital/ 
Brigharn and Women's Hospital 

Jeffrey Gelfand 

University of California- 
San Francisco 

David Hwang 

Harvard Medical School/ 
Massachusetts General Hospital/ 
Brigharn and Women's Hospital 


Emanuela Binello 

Mount Sinai School of Medicine, 
New York City 

Paul Gigante 

Coi^n-ibiQ University 

Ning Lin 

Harvard Medical School/ 
Brigharn and Women's Hospital 


Andrea Dalve-Endres 

University of California- 
San Frcr'cisco 

Anjelica Garza 

Brigham and Women's Hospital 

Rachel Peragallo 

Duke University Medical Center 

Kivnta Phillips-Arnold 

M.orehouse School of Medicine 

Luwam Semere 

Brigharn and Women's Hospital 


Jason Comander 

Massachusetts Eve & Ear Infirmary 

Esther Huong 

Wilmer Eye Insitute at 
Johns Hopkins, Baltimore 

Brandon Lee 

University of Southern California, 
Los Angeles 

Lauren Patty 

University ot oouthern California, 
Los Angeles 


Matthew Jocobsen 

M'.cssQc'-ii^ setts General Hospitol 

Jose Ramirez 

M\assacnusetts General Hospital 

Basel Sharaf 

Massachusetts General Hospital 


Corinna Franklin 

University ot Southern California, 
Los Angeles 

Duretti Fufa 

Hospital for Special Surgery, 
New York City 

Daniel Guss 

Massachusetts General Hospital 

Keith Michael 

Du^t u'liveiiitv Medical Center 

Chealon Miller 

University of Virginia, Charlottesville 

Nader Nassif 

Barnes-Jewish Hospital, St. Louis 

Levels Shi 

Massachusetts General Hospital 

Jeremy Smith 

Massachusetts General Hospital 


Mia Edwards 

UCLA .Medical Center 

Kiron Kakaralo 

Massachusetts Eye & Ear Infirmary 

Amanda Munoz 

Stanford University Programs 


Bertrand Huber 

University ot Washington 
Affiliated Hospitals 


Brian Anderson 

Massachusetts General Hospital 

Birthday Bash 

HMS alumni and faculiA' arc invited 
to three scientific symposia celebrat 
ing the centennial of the Schoors 
Longvvood Quadrangle. The sym- 
posia, scheduled for September 21 
and 22, will highlight research on 
the brain, molecular and cellular 
bases of infection, and cancer genet- 
ics and gene based drug discovery. 
To learn more, visit http:/7hms. 

Top of the Heap 

Harvard Medical School has again 
taken the lead spot in U.S. News &■ 
World Report's annual listing of 
the nation's outstanding graduate 
schools, attaining an overall per 
feet score and placing first among 
the nation's medical schools in the 
research category. Following HMS 
in the top fi\'e were Johns Hopkins, 
the Uni\'ersity of Pennsyl\'arLia, the 
University of California-San Fran- 
cisco, and Washington University. 

Six of One 

Advances in cancer nanotcchnolo 
gy will be the focus of the Sixth 
Annual HoUis L. Albright, M.D. '31 
Symposium, slated for 4;30 p.m. 
on October 5 in the New Research 
Building, 77 Avenue Louis Pasteur, 
Boston. Featured speakers will 
include Judah Folkman '57, the 
Julia Dyckman Andrus Profes.sor of 
Pediatric Surgery at HVIS, and 
Robert Langer, institute professor 
at MIT. For more information, 
call 617-384-8469 or email events® 




r T.SK 



Amy Antman 

Elizabeth Pinsky 

Elisa Cheng 

Scott Hunter 

University of California- 

Massachusetts General Hospital 

Cambridge Hospital 

M\assacrii^setts General Hospital 

San Francisco 

Suhas Radhakrishna 

Suzanne Dieter 

Yanerys Ramos 

Allon Beck 

Children's Hospital Los Angeles 

New York Presbyterian 

UCIA Medical Center 

Massac hijsetfs General Hospital 

Brian Skotko 


Hillary Rolls 

Vassilios Bezzerides 

Children's Hospital Boston 

Joanna Epstein 

Ay\assachusetfs Generol Hospital 

Children's Hospitol Boston 

Jacob Ulm 

University of Colifornia- 
San Francisco 

Amado Sussmann 

Chelsea E. F. Bodnar 

UCLA Medical Center 

New rorK university 

University of Washington 
Affiliated Hospitals 

Katherine Yun 

Alysia Han 

University of California- 

School of Medicine 

Matthe>v Eisenberg 

Yale-New Haven Hospital 

San Francisco 


Children's Hospital Boston 
Petros Giannikopoulos 


Carlos Saavedra 

New York University 
School of Medicine 

Sarah Billmeier 

Brigham and Women's Hospital 

University of California- 

San Francisco 

Dorothy Weiss 

Beota Zolovska 

Dante Foster 

Samantha Goldstein 

University of California- 

HMS/Spaulding Rehabilitation 

New York Presbyterian 

Universi^/ of Washington 
Affilioted Hospitols 

San Francisco 

Antonio Henry 

Sanjiv Harpavat 



Brigham and Women's Hospital 

Baylor College of Medicine, 

Ryan Egeland 

Northwestern McGaw, Chicago 

Robert Den 

William Kitchens 


Thomas Jefferson University, 

Massachusetts General Hospital 

Saria Hassan 

Dzifa Kpodzo 


Johannes Kratz 

Yale-New Haven Hospital 

Brigham and Women's Hospital 

Simona Deutsch 

Massachusetts General Hospital 

Paul Hyman 

New York Presbyterian 

Charles Lord 

Massachusetts General Hospital 



University of Colorado School 

Shreya Kangovi 

Hospital of the University of 
Pennsylvania, Philadelphia 

Maria Almond 

Lia Halasz 

Brigham and Women's Hospital 

of Medicine, Denver 

Duke University Medical Center 

Raymond Mak 


Brigham and Women's Hospital 
Danielle Margalit 

Timothy Doskivich 

UCLA School of Medicine 



Brigham and Women's Hospital 

Mohummad Siddiqui 


David Miyamoto 

M'lassacnusens General Hospital 


Brigham and Women's Hospital 

Aisho Taylor 


William Polkinghorn 

Northwestern University 

«^ - ,^^^^^^l^^^^^l 

Miemorial Sloan-Kettenng 

Feinberg School 

-« ^ll^^^^^l 

Amish Shah 



New York Presbyterian 

^^B ^>h J^Bs^ 

Victoria Wong 

David Berry 

Principol, Flagship Ventures, 

■ O^' ^ 


Brigham and Womens Hospital 

Cambridge, Massachusetts 



Jay Chyung 

Consultant, Boston Consulting 

Group, Boston 

^^^^^^B ' ' "^^^^^1 

Jennifer Broder 

Boston Universit/ Medical Center 
Brian Bronzo 

Angel Foster 

Research, Ibis Reproductive Health, 
Cambridge Massachusetts 

^^^^B ' »-^^^^^^^l 

Massachusetts General Hospital 

^^^v ^,J^^^^^^^^^^^I 

Neil Hattangadi 

^■' ' ''^jHfl^^^^H 

Gloria Chiang 

Associate, McKinsey and 



University of California- 

Company, Boston 



San Francisco 



Pardis Sobeti 



Robert Hayter 

Postdoctoral Fellowship, 


i l^^H 

Hospitol of St. Raphael, 

Brood Institute, Cambridge, 



New Haven, Connecticut 






Innovations on Tradition 


overflow crowd filled the tent on Alumni Day to 
hear inspiring personal stories from four Harvard 
Medical School-affiliated Nobel laureates — 
David Hubel, Bernard Lown, Joseph Murray "43B, and 
Thomas Weller '40, A forthcoming issue of the Bulletin will 
report in more detail on this fascinating session. As a warm- 
up act, the attendees heard highlights of the Alumni Coun- 
cil's activities during the past year, a period of both transi- 
tion and progress. 

George Thibault '69 faced the challenge of following a 
legend, Dan Federman '53, as director of alumni relations. 
Undaunted, George plunged into his new role with energy, 
insight, and a commitment to work closely with HMS alumni. 
Now that the staff members of the alumni office share space in 
the Landmark Center (the old Scars Building) with staff of the 
Office of Resource Development and the Bulletin, George has 

Dean Joseph Martin pledged that if unrestricted alumni giv- 
ing — the Harvard Medical Alumni Fund — increased by more 
than $70,000, we could eliminate the need for parental contri- 
butions for families whose incomes fall below $40,000 annual- 
ly. Well, we beat that target with much to spare. The 2006 cam 
paign has already raised $1,375,000, compared with $780,000 in 
2005. This means that an estimated 20 entering medical stu- 
dents will not need to ask their low- income families to support 
their education. A forthcoming Bulletin article will chronicle the 
impact of debt on students' — and alumni's — lives and careers. 
The Council intends to continue working with Dean Mar- 
tin on ways to improve this situation. It will also seek to link 
HMS alumni with the superb continuing medical education 
opportunities that Harvard offers in Boston, throughout the 
country, and online. The Council will probe the increasingly 
sophisticated database of the university's alumni office to 
offer HMS alumni the capabilities of contacting classmates 

This fall HMS will launch a curricular reform for both 
the preclinical and clinical years. Hundreds of faculty 
members have participated in the planning for this reform. 

been proposing ways to take ad\antage of this proximity to 
communicate more effecti\'ely with HMS alumni. 

Another important transition is the well publicized step 
ping down of Harvard President Larry Summers and the 
resultant uncertainty about the pace of development of the 
new facilities in Allston, the timing of Harvard's next major 
fundraising campaign, and the status of proposed new uni- 
versity-wide initiatives in biomedical research. 

I am pleased to report that the Bulletin has won yet anoth 
er honor — a gold medal from the Council for Advancement 
and Support of Education in the special constituency maga- 
zine category. The judges noted that the Bulletin was "far and 
away the gold-medal winner in terms of splendid writing 
and elegant design. The writing consistently captures tangi- 
ble, personal aspects of difficult stories." Congratulations 
not only to editor-in-chief Bill Bennett '68, editor Paula 
Byron, associate editor Ann Marie Menting, and assistant 
editor Janice O'Leary, but also to the alumni, faculty, and stu 
dent authors who are the Bulletin's principal contributors. 

We have good news to report about student indebtedness. 
As you may recall from the Winter 2006 issue of the Bulletin, 

and other colleagues, to learn more about the myriad activi- 
ties at HMS, and to foster mentoring opportunities for grad- 
uates who choose not to remain in the Boston area. 

Finally, under the leadership of Jules Dienstag, the dean for 
medical education, and with the strong support of Dean 
Martin, this fall HMS will launch a curricular reform for both 
the prechnical and chnical years. Hundreds of faculty mem- 
bers have participated in the planning for this reform, which 
the medical students view with enthusiasm. 

As you will learn in the upcoming accounts by Harvard 
Medical School's Nobel laureates, their experiences as medical 
students were formative in helping them develop intellectual 
curiosity, set standards of excellence, foster independent 
thinking, and work collaboratively with colleagues. Few of us 
will get the call from Sweden, but we ha\'e all benefited from 
those same experiences. ■ 

Steven A. Schroeder '64 is a distinguished professor of health and health 
care in the Department of Medicine at the University of California at 
San Francisco, where he also directs the Smoking Cessation Leadership 
Center He can be reached at schroeder&^medicme.ucsfedu. 











Diabetes Diet 

|li| .*** 

O « • 4. 


Healthy Aging 

A Lifelong Guide to Your Physical and 
Spiritual Well-Being, by Andrew Weil "68 
(Knopf, 2006) 

Although aging is an irreversible process, 
Weil says we can do a great deal to keep 
our minds and bodies in top working 
order. He discusses the science of aging 
and recommends an anti-inflammatory 
diet to protect the immune system 
and enhance adaptation to the body's 
changes. He also coaches readers on 
stress management and exercise. 

Zen-Brain Reflections 

RevicwmgRecent Developments in Meditation 
and States of Consciousness, by James H. 
Austin '48 (MIT Press, 2006) 

In his second book on the links between 
meditation and neurology, Austin 
reviews the latest studies on the 
regions of the brain that transform 
with meditation and explores how 
imaging methods can better monitor 
the effects of meditation. A clinical 
neurologist and Zen practitioner, the 
author also discusses altered states of 
consciousness and how Zen meditation 
can help illuminate neuroscience. 

The No Sweat Exercise Plan 

Lose Weight. Get Healthy, and Live Longer, by 
Harvey B. Simon '67 (McGraw-Hill 2006) 

well, recants and here urges readers to 
reap the benefits of exercise by modify- 
ing their daily routines. He offers a 
point system — a half hour of dusting 
equals 75 points and a half hour of golf- 
ing equals 145 points — to quantify 
activities that promote better health 
and help shed pounds. 

Global Health Leadership 
and Management 

edited by William H. Foege, Nils 
Daulaire '76, Robert E. Black, and 
Clarence E. Pearson (jossey-Bass, 2005) 

This book looks to the success of the 
for-profit management \\'orld for mod- 
els on how to return the investment of 
public health efforts as measured by 
morbidity and mortality. Contributors 
to this book point out that although sci- 
ence is essential to solving global health 
crises, science alone is not enough. The 
book uses lessons learned through immu- 
nization programs and new approaches 
to the HIVAIDS epidemic. 

Dr. Buynak's 1-2-3 Diabetes Diet 

A Step by Step Approach to V^'eight Loss 
Without Gimmicks or Risks, by Robert J. 
Buynak '95 with Gregory L. Guthrie 
(American Diabetes Association, 2006) 

The author, once an advocate for intense 
aerobic exercise as the only way to stay 

This guide encourages those with type 2 
diabetes to control their blood sugar lev- 
els by making smarter food and exercise 
choices. The author includes a food diary, 
a case study, and chapters on reading 
food labels and calorie counting. Helpful 

hints for sticking with new diet and 
exercise regimens round out the book. 

Every Mother Is a Daughter 

The Ncverendmg "^ucst for Success, Inner 
Peace, and a Really Clean Kitchen, by Petri 
Klass '86 and Sheila Solomon Klass 
(Ballantine Books, 2006) 

This volume is part memoir, part tra\'el- 
ogue, and part comersation between the 
mother and daughter coauthors. It's 
filled with admissions that re\'eal their 
similarities — such as a shared disdain 
for suburban New Jersey — and their dif- 
ferences — an unswept doorstep that 
niggles at Sheila doesn't even register 
with Petri. The authors alternate their 
commentary on such topics as child- 
birth, careers, vanity, and India. 

50 Years Out 

P/ivsicians Reflect on Our Times, edited by 
Fritz Loewenstein "53, A. Scott Earle "53, 
and Donald N. Wysham "53 
(Hollis Publishing, 2006) 

Tw^enty-two members of the HMS Class 
of 1953 have written thoughtful essays 
for this collection on topics ranging 
from Iraq to malpractice to aging. One 
physician muses on the resfUence of the 
abused dogs he volunteers to care for at 
a shelter, another chronicles the sur- 
prising results from his research on the 
mother-infant bond in East African 
populations, and yet another compares 
doctors nearing retirement to Prospero 
in Shakespeare's The Tempest. 




The Denial of Aging 

Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, 
by Muriel R. Gillick 78 (Hanwd University Press, 2006) 


the bus to Shre\eport, Louisiana, to play craps, and could 
dominate the Texas Hold 'Em table if tremor didn't make 
holding a hand so hard, which is good luck for the other play 
ers. Last week, he called the only doctor in the family — a psy- 
chiatrist — for an emergency urological consultation. He had 
just been told he had a PSA of IL 
He thought he might have cancer. 

1 happened to be reading The 
Denial of Aging: Perpetual Youth, Eter- 
nal Life, and Other Dangerous Fantasies 
when he called. I was in the mid 
die of a sentence, one of many I 
would like to read out loud to 
everyone who is elderly or lo\'es 
someone who is old — an inclusive 
population. "The truth is," I was 
reading, "that at the very end of 
life, death is no longer an 'alterna- 
tive.'" The author, Muriel Gillick '78, 
had just pointed out that screen 
ing for prostate cancer in the 
elderly, instead of screening for 
poor hearing or poor balance, is 
"vainly trying to stave off the 
wrong conditions." Uncle Morris 
has poor hearing and poor bal- 
ance. He has never called me to say 

they've been tested or treated. Why wasn't his doctor wor 
rying about them? Why wasn't Uncle Morris? 

This energetic book belie\'es it knows why. Acoustics and 
balance are small change when vou are fighting to the death 
with death itself. We are driven by the uncontrollable 
(though understandable) urge for self-preservation and 
remain convinced that "the secret weapon against illness is 
prevention." This being America, of course, no one expects 
eternal good health for free; we're not unreasonable. We 
know we need to earn it. So we pay top dollar for diets and 
supplements, annual batteries of blood tests, comprehensive 
exams for old men, and mammograms for elderly women. But 
then — as if life were contractual — we expect deli\-ery of per- 
petual youth. As Gillick explains, "in keeping with the belief 
that we can control our destiny, we beUeve we will succeed." 

Yet prevention "takes on a new meaning in old age," 
because, even in America, old age cannot be prevented. 
Inevitable chronic illnesses need management instead of 
aggressive intervention, "watchful waiting" instead of revolv- 


ing hospital admissions, less technology, more kindness, and 
an end to denial. "Pneumonia," Gillick writes with shocking 
good sense, "can be the old person's best friend." 

Gillick is unafraid of a solid nine rounds in the ring. She jabs 
at Medicare first. It certainly makes sense (though apparently 
not to the government) that three different 70-year-old men 
might need three different levels of health care. Benefits should 
be assigned on the basis of health status and not birth date, she 
argues. We ought to ha\'e one Medicare for "robust older peo- 
ple" (this might co\'er their glasses and hearing aids, dentures, 
and drugs); a second Medicare for those with multiple chronic 
diseases; and a third for hospice 
associated palliative care. Her rea 
soning is so efficient and well placed, 
and she illustrates it so well with 
cases, that by the end of the chap- 
ter. Medicare can only limp back 
to its corner. 

Next Gillick spars with tradi 

tional nursing homes — but not lor 

the reason most critics take them to 

task. She has no complaints about 

slovenly substandard care; in fact, 

"some have claimed that the only 

industry. . . more tightly regulated in 

.America than nursing homes is the 

nuclear power industry." Standard- 

vj ^ -j^- ization has taken priority over qual- 

^9h' ,.JpK? -^ ity of life — the preoccupation is 

K'^jr tS^i;:^ J uith safety (and generic measure- 

M ■ M ments) rather than with such needs 

""^ \,^^0r S"^ as comfort and companionship. 

Even assisted living facilities, 
popularly viewed as a graceful solution for those who can 
afford them, take their pounding. In her view, they are uncre- 
ative environments, ill equipped to handle physical impair 
ments or dementia. Old people deserx'c better. 

Instead, GiLLick suggests that assisted li\-ing and nursing home 
care should be variants of a single model, points of extrapolation 
along a single line according to increasing need. Three le\'els of 
comprehensive long-term care could be paid for by one source. 
Her detailed descriptions are dazzling in their sensibleness. 

This is the informed, compassionate, reaUstic gerontologist 
you want for your grandmother, your mother, and eventual- 
ly — if she is not too old by then — yourself. At the end of her 
book, GUhck allows herself a social commentary on the mean- 
ingful life. "The idea that it's fine [for the elderly] to stop 
gi\'ing and . . . start taking," she writes, "is like advocating an 
all-dessert diet." Live better by taking less and gi^Tng more. 
Certainly. But no matter what you do, you won't h\'e forever. ■ 

Elissa F\y '%% is a psychiatrist at the Massachusetts Mental Health Center 


R E N C H M A R K S 


Attention, Shoppers 


curse, an entertainment, even 
a sport. Over the years mar- 
keters have spent bilUons try- 
ing to understand the prompts to shop. 
But how humans decide what to put in 
their carts, bags, or driveways 
may now be a bit clearer thanks 
to recent research involving 
some cousins to our species. 

In a .study that po.sed a neu- 
robiological question in the 
language of economic theory, 
HMS researchers have found 
neurons that appear to process 
subjective choices in monkeys. 

"We're often told we carit 
compare apples and oranges, 
but truly we do it all the time," 
says Camillo Padoa-Schioppa, 
an HMS neurobiology research 
fellow and first author on the 
study, pubhshed in the April 23 
issue of Nature. "Behavioral evi- 
dence suggests that choice 
results from two distinct 
processes. First, you assign val- 
ues to the available options, 
and then you make a decision 
based on those values. 

"We've long known that dif- 
ferent neurons in various parts 
of the brain respond to separate 
attributes, such as quantity, 
color, and taste. But when we 
make a choice, for example, 
between different foods, we 
combine all these attributes — we 
assign a value to each available item. The 
neurons we've identified encode the 
\alue individuals assign to the available 
items when they make choices based on 
subjective preferences, a behavior called 
'economic choice.' " 

Our lives are tilled with choices great 
and small: work without breaks or punc- 
tuate our hves with periods of vacation 
and relaxation, invest in stocks or put 
our money in bonds, choose the chicken 

burrito or the one with only beans and 
cheese. The behavior behind our making 
such choices has been fodder for much 
study by economists and psychologists. 
Some of the more perplexing findings 
ha\'e come from behavioral economics 

research showing that people's choices 
often \'iolate the rules of economic ratio- 
nality. In their efforts to tease out the rea- 
sons behind such results, scientists have 
begun to probe the neural bases of eco- 
nomic choice. It is to this emerging field 
of "neuroeconomics" that the research 
of Padoa Schioppa and colleague John 
Assad, an HMS associate professor of 
neurobiology, is contributing. 

For the study, the two researchers 
recorded the electrical acti\ity of 931 neu 

tons of two monkeys, male and female, 
and correlated that acti\ity v\-ith the ani- 
mals' beha\ior. In each session, the mon- 
keys chose between \'ar)ing amounts of 
different beverages, including grape juice, 
apple juice, peppermint tea, diluted cran- 
berr}' juice, lemonade, and fruit 
punch. They selected their 
juices by looking at representa- 
tive squares on a computer 
screen. The scientists identified 
dedicated neurons in the orbito- 
frontal cortex (OFC), located 
above the eyeballs, that appeared 
to assign a \'alue to each bever- 
age based on quahty and quanti- 
ty. "They kick in right away," 
Padoa-Schioppa says, "most 
prominently when presented 
with an offer." 

As the researchers watched 
the monkeys' behavior, they 
observed tradeoffs between 
juice type and juice quality. A 
monkey might choose grape 
juice when one or two drops of 
apple juice are available. But 
the monkey may also show no 
real preference when instead 
offered one drop of grape juice 
and three drops of apple juice. 
Or, the animal might always 
choose apple juice whenever 
four or more drops of it were 
made a\'aLlable. Such behavior 
indicates that the value the 
monkey assigns to one drop of 
grape juice is roughly equal to the value 
the monkey places on three drops of 
apple juice. 

On the basis of such choice patterns, 
Padoa-Schioppa and Assad correlated 
the acti\'ity of neurons in the OFC with 
the \-.ilues assigned to the two juices. 
Low acti\ity in one neuron might be all 
that registers when the monkey chooses 
one drop of grape juice or three drops of 
apple juice. Nledium-high acti\it}' might 
be measured in the same neuron when 


the monkey chooses two drops of 
grape juice or six drops of apple 
juice. The same neuron might show- 
high activity when the monkey 
sekcts three drops of grape juice or 
ten drops of appk juice. Such resuks 
mean that the activity of the neuron, 
and its cousins in the OFC, encodes 
the value chosen by the monkey 
independent of the physical charac- 
teristics — such as taste and quah 
ty — of the beverage. 

In the key finding, another group 
of neurons in the same area encodes 
the value of only one of the two juices 
offered to the monkey. Some neurons 
encoded the value of the grape juice 
while others encoded the value of 
the apple juice. 

.•\n important aspect of the results 
is that neurons in the OFC encode 
the economic value of the offered and 
chosen juice independent of the par- 
ticular way the be\'eragc is offered 
and independent of the specific action 
the animal uses to signal its choice. 
"This suggests," Padoa-Schioppa says, 
"that economic choice is, at its 
essence, a choice between goods 
as opposed to a choice between 
actions — such as reaching to the 
right to take the apple or to the left 
to take the orange." 

"We have a pretty good idea of 
how the brain handles the incom 
ing sensory information and, on the 
output side, of how the brain con- 
trols movements we make to exe- 
cute our choices," says Assad. "We 
found a part of the brain that seems 
to be involved in governing deci- 

The neural mechanisms for deci- 
sion-making may also provide 
insight into certain psychiatric dis- 
turbances, such as addictions. Peo 
pie with lesions in the OFC, the 
researchers say, often show aberra- 
tions in choice behavior. ■ 

Perchance to Dream 


amount of shut eye 
can be difficult 
when responsi- 
bilities are many, days run 
long, and minds boil with 
thought even when the body 
slips to horizontal. Resting and 
recharging become less possible 
when slumber is relegated to off 
hours, time periods that do not syn- 
chronize with those encouraged by 
the body's circadian cycle. 

Rejuvenating slumber may now be 
more than just a dream for those who 
are sleep-challenged. Research by a 
team of scientists in the Division of 
Sleep Medicine at Brigham and 
Women's Hospital has shown that 
melatonin, taken orally during nontypi- 
cal sleep times, not only can help 
people fall asleep but can also 
help them slumber soundly. The team, 
which includes senior scientist Charles 
Czeisler, chief of the Division of Sleep 
Medicine, reported its findings in the 
May 1 issue of Sleep. 

The hormone melatonin definitely 
likes the nightlife. It is produced only 
during darkness; bright light hitting 
the eye's retina acts as a signal to 
stop its production. In humans, this 
cyclic secretion of endogenously pro- 
duced melatonin serves to mark 
phases for the suprachiasmatic nucle- 
us, a bundle of neurons in the hypo- 
thalamus that acts as the body's inter- 
nal clock. Boosting endogenous 
melatonin with pharmacologic doses 
has been shown to shift circadian 
phases in humans, a characteristic 
that has led millions of people to 
take supplements in the hope of 
improving their sleep. 

The Division of Sleep Medicine 
team designed a study to assess mela- 
tonin's effects on slumber. They enlist- 
ed 36 men and women between the 
ages of 1 8 and 30 in a two-month 
study. First, participants spent three 
weeks distancing themselves from 

substances that 
could affect sleep — 
caffeine, nicotine, 
alcohol, and pre- 
scription and non- 
prescription medica- 
tions. The researchers 
then sequestered each 
participant in a sound- 
proof suite free of time clues. 

After three days and nights of 
traditional sleep schedules, the 
researchers placed the participants 
on a three-week regimen that shifted 
their sleep pattern to a 20-hour 
sleep-wake schedule, one that mim- 
icked what a person traveling east- 
ward through four times zones every 
day would experience. During those 
three weeks, participants received a 
placebo, a 0.3-milligram dose of 
melatonin, or a 5-milligram dose of 
the hormone 30 minutes before retir- 
ing. The differing doses were used 
only as comparisons to the placebo. 

The researchers found that during 
the 6-hour, 40-minute sleep periods, 
the participants who took melatonin 
slept more than those who took the 
placebo — up to 84 percent of the 
time allotted versus 77 percent in the 
placebo group. Participants' sleep 
efficiency did not differ, however, 
during times when melatonin was 
being produced in the body. 

"Melatonin enabled participants 
to obtain on extra half hour of sleep 
during the day, at a time when they 
were not producing melatonin them- 
selves," says Czeisler, "but it did not 
help them sleep at night, when their 
bodies were producing the hormone. 
This finding has implications for mil- 
lions of people who attempt to sleep 
at times that are out of sync with the 
brain's internal clock." ■ 





The Mettle of Gold 


been the most prized of met- 
als, yet in the medical realm, 
it has endured a lowly status. 
Although gold has occasionally been used 
to treat ailments such as heart disease, 
syphihs, and alcohohsm, most physicians 
deemed it useless — except perhaps to 
"soothe an itchy palm" or as "an antidote 
to po\'erty." The metal gained some scien- 
tific luster in 1929, when a dashing young 
Frenchman, Jacques Forestier, began gi\'- 
ing gold salts to his rheumatoid arthritis 
patients. News spread of the therapy's 
success. Twent)' years later, his work was 
upstaged by research on pioneering — 
and, it would later turn out, Nobel 
Prize-winning — ^work on the use of cor- 
tisone in rheumatoid arthritis. 

Forestier's therapy had something else 
going against it — no one had been able 
to figure out exactly how gold worked 
to alleviate rheumatoid arthritis. 

Now, Brian DeDecker, Stephen De 
Wall, and their colleagues at HMS report 
in the February 27 issue of Nature Chemi- 
cal Biology that they have found an 
answer, one that could enhance gold's 
reputation in medicine, \kire than that, 
the discovery could lead to a safer, more 
effective version of gold therapy. 

"Gold is still widely used in some 
countries, such as India," says Timothy 
Mitchison, the Hasib Sabbagh Professor 
of Systems Biology and a coauthor on the 
study. "It works. The main problem is its 
side effects. Gi\'en our new hypothesis for 
a gold mechanism, it might be possible to 
do something about those side effects." 

Raising the Gold Standard 

like other autoimmune diseases, rheuma- 
toid arthritis occurs when the cells of the 
immune system begin attacking the 
body's owTi tissues, in this case the deU 
cate s)Tiovial membrane lining the joints. 
Researchers still do not know what 
exactly provokes this attack, but it is 
thought to in\'ol\'e the major histocom- 

patibility complex (MHC) class II pro- 
teins. Normally, these proteins sit on the 
surface of a special class of immune cell, 
holding bits of foreign protein in their 
grip. This MHC class Il-peptide com- 
plex is seen by other immune cells, which 
then launch an attack on cells bearing 
that same complex. DeDecker and De 
Wall, HMS research fellows in cell biolo- 
gy, and their colleagues found that gold, 
along with other precious metals such as 
platinum, frees peptides from the grip of 
the MHC class II proteins, essentially 
disarming the immune response. 

It is not clear what peptides might be 
pushed out by gold therapy in actual 
rheumatoid arthritis patients, largely 
because of the mystery surrounding the 

disease. One possibilit}' is that these pep- 
tides are bloodborne bacterial or \iral 
antigens that ha\e become trapped in the 
joint. .Mother is that these compounds 
are foreign antigens that closely mimic 
host peptides, confusing the immune sys- 
tem and turning it against native antigens. 

Nor is it clear how, exactly, gold frees 
the putative antigen from MHC class 
II's grip. The researchers, who conduct- 
ed their experiments at the School's 
Institute of Chemistry and Cell Biology 
(ICCB), have evidence that it may work 
by subtly changing the shape of the 
MHC class II proteins. 

DeDecker and De Wall were not 
looking for gold when they began their 
study; they were chasing the dream of 

''Gold works. The main problem is its side 
effects. Given our new hypothesis for a 
gold mechanism, it might be possible to 
do something about those side effects." 




the late Harvard Uni\'ersity structural 
biologist Don Wiley, who had made 
the first crystal structure of an MHC 
class Il-peptide complex. Wiley invited 
DeDecker and De Wall to help him 
knock those peptides out. 

The researchers spent the next eight 
months setting up the cleanest assay they 
could de\'ise. With help from Stephen 
Harrison, HMS professor of biological 
chemistry and molecular pharmacology, 
they began screening tens of thousands 
of compounds in the ICCB Library. They 
got no hits. The pair decided to screen 
about 600 FDA approN'ed drugs and got 
two .solid hits — a pair of anticancer 
drugs, cisplatin and carboplatin, both of 
which happen to be metals. 

At first, DeDecker felt disappointed 
until De Wall pointed out that these 
types of compounds arc used therapeu 
tically for rheumatoid arthritis. The duo 
decided to test the drugs' mettle. Nor- 
mally, MHC class II proteins exchange 
peptides with the aid of a catalyst, 
HLA DM. In their original screen, they 
had included HLADM along with 
MHC class II and a human leukocyte 
antigen. This time, they left HLADM 
out. The platinum-based drugs still 
knocked the peptide off. Other tests 
showed that only gold and palladium 
exhibited the same peptide-releasing 
powers as platinum. 

Meanwhile, at the University of 
Massachusetts Medical School, scien- 
tists had created an antibody for pep- 
tide-free MHC class II protein. It turned 
out the metal-MHC complex bound the 
antibody, suggesting the metal was 
keeping MHC class II free of peptide. 

The researchers are cautiously opti- 
mistic about the prospects of a revival of 
gold's use in medicine and the develop 
ment of less toxic therapies. "Academic 
and industry groups have shown a lot of 
interest," Mitchison says. ■ 

Misia Landau i.s the senior science writer 
(or Focus. 


Experiencing a sudden cardiac death during exercise is less of a risk for 
women who engage in two or more hours of moderate to vigorous activity 
each week — jogging, running, biking, swimming laps, or playing tennis or 
squash — than it is for women who exercise at these levels less than two hours 
per week. This finding, from a two-decade study of 85,000 participants in the 
Nurses' Health Studies at Brighom and Women's Hospital, indicates that regu- 
lar, moderate to vigorous exertion benefits women, says lead researcher, 
Christine Albert, director of the hospital's Center for Arrhythmia Prevention and 
an assistant professor of medicine at HMS. The research appeared March 22 
in the early-release issue of the Journal of the American Medical Association. 


A possible genetic link to binge eating disorder has been found by researchers 
at McLean Hospital. In the March 6 issue of Archives of General Psychiatry, 
lead author James Hudson, HMS professor of psychiatry at McLean, reports 
that family members of obese people with binge eating disorder were twice as 
likely to manifest the disorder when compared with family members of obese 
people without the condition. Individuals with the disorder, which affects 
between one and five percent of the U.S. population, have uncontrolled eating 
binges at least twice a week for a minimum of six months. Hudson hopes this 
finding will spur the development of specific treatments for the condition. 


Other things remaining equal, the substitution of noncaloric beverages for 
sugar-sweetened ones can markedly decrease body mass indexes in teens. 
Children's Hospital Boston pediatric researchers Cora Ebbeling, an HMS assis- 
tant professor, and David Ludwig, an HMS associate professor, enrolled 1 03 
people aged 1 3 to 1 8 in a six-month study testing the weight-related effects 
of sugary versus non-sugary beveroge consumption. Half the group received 
weekly home deliveries of bottled waters and artificially sweetened drinks; 
the remaining teens served as a control group. When the study ended, 
researchers found that heavier teens in the group avoiding sugary drinks lost 
weight while similar teens in the control group had slight increases in weight. 
A group-to-group comparison showed a difference of almost one pound each 
month. The findings appear in the March issue of Pediatrics. 


Asthma sufferers become breathless when their lungs' airways constrict, a 
response long attributed solely to the activities of type 2 helper cells. Recently, 
scientists at Children's Hospital Boston looked at cells from the lungs of patients 
with moderate to severe asthma and discovered that airway tightening in more 
than half the participants was triggered by different cells: natural killer Ts (NKTs). 
Unlike the helper cells, NKTs are activated by glycolipids, which resist the action 
of corticosteriods typically used to treat asthma. Lead author Dale Umetsu, 
Prince Turki Bin Abdul Aziz Al-Saud Professor of Pediatrics at HMS, reports the 
findings in the March 16 issue of the New England Journal of Medicine. 




offer sinners. For those who 
wish to wallow in sin, physi- I 
cians can prescribe Viagra to 
facilitate lust, Ambien to fos- 
ter sloth, or Prozac to boost pride. Antidotes to sin are less effecti^'e: 
appetite suppressants for gluttony or beta-blockers for wrath. The 
treatments for envy and greed remain the purview of the clergy. 

Patients today should, nevertheless, feel blessed. In the medieval 
tradition, each sin warranted its particular punishment in the next 
life rather than a prescription in this. Those who had succumbed to 
lust were smothered in fire and brimstone; gluttons choked down 
rats, toads, and snakes; the greedy were boiled in the finest oil. The 
slothful were pitched into snake pits, while dismemberment await- 
ed the wrathful. The envious faced submersion in freezing water, 
and the prideful were broken on the wheel. 

In these pages our physician authors seek not to cure their patients 
of sin but to explore the roles that the seven deadly sins have playec 
in their own professional and personal lives. 


s,il", ^1'- 









an essay about doctors and pride, 
and they immediately start to 
snicker. One doctor friend launched 
into his favorite joke: How many 
medical students does it take 
to change a lightbulb? (One, to ]^y PERRI KLASS 
stand there and wait for the 
world to revolve around him.) 

Several others offered anecdotes — the arrogance of a physician who doesrit 
bother to learn the names of non-doctor colleagues, the rudeness of a doc- 
tor who never returns calls, the boorishness of a doctor who leaves his 
dirty dishes in the conference room. 




How does pride show up? I remember my first beeper and how 
I wore it, ostentatiously, at parties, and gestured toward it, 
occasionally, in restaurants, to explain why 1 wasrit ordering wine. 


I protested, a little weakly, that char- 
acter is more complicated than that. 
Those doctors may simply be plagued 
with a weak memory, or poor social 
skills, or bad manners; it wasn't fair 
to interpret everything as just more 
evidence of the massive medical ego. 
But these were all doctors telling the 
stories, and, truth be told, they were 
more than a little self-satisfied in the 
telling — they were, each and every one 
of them, profoundly proud of having a 
keen eye for overly arrogant colleagues. 

The issue of pride — -and the percep- 
tion of pride — permeates medical 
practice. You could call it doctors' 
besetting sin. It's part of almost every 
chche about our beha\'ior — and misbe- 
havior. I can think of two jokes right 
this minute about doctors and our 
overweening pride — one is completely 
unprintable, while the other opens 
with a fellow making it up to heaven. 
While the recently deceased is stand- 
ing at the Pearly Gates, St. Peter points 
out a bearded gentleman strolling by 
in a long white coat. "Look!" St. Peter 
says. "There goes God. Sometimes he 
just likes to play doctor." 

During medical school, I started 
writing about my training. I could not, 
of course, make myself out to be the 
dramatic hero of my own story, for 
the very good reason that my ignorance 
of medicine generally made me the 
least useful person in any clinical situ- 
ation. And yet somehow, over and over 
again, I found myself in a starring role 
in my narratives. I would tell stories 
about doctors — ^yes, more senior, more 
highly trained clinicians, people who 
actually knew what to do with a sick 
patient — who were still, somehow, 
insufficiently sensitive to pick up all 
the nuances and emotional intricacies 
that I, the medical student, could so 
clearly understand. Many of my best 
stories poked fun at more senior doc- 
tors who were a bit too arrogant, more 
than a little too full of themselves. 


A resident on one clinical rotation 
taught our whole team the fine art of 
distracting an attending during rounds 
by leading him, with gentle flattery, 
into expounding on his own pet sub- 
ject for the entire hour. All it took 
was a comment about what a wonder- 
ful opportunity it was for medical stu- 
dents to hear about this or that from 
such an eminent authority. And we all 
got to rest and relax — no tricky ques- 
tions about the patients, no chance of 
discovering that we had not actually 
read up on the assigned subject from 
yesterday. Imagine my surprise, now 
as an attending, to realize my own vul- 
nerability to the same tactic: Simply 
v/hisper that it would be an honor and 
a privilege to hear me ride my own 
hobbyhorse or talk about myself, and 
I will happily abandon other subjects 
and oblige. After all, what could possi- 
bly be more riveting for medical stu- 
dents? In fact, for everyone! 

Here Comes the Pride 

Pride doesn't always carry a negative 
connotation, of course; pride can mean 
a rightful and proper joy in your own 
prowess or accomplishment — or in 
that of someone you care about. Look 
at parents on graduation day and you'll 
see pride as a positive and rewarding 
force, or at least as a forgivable glow 
that burnishes certain occasions. As 
a resident in pediatrics, I took a real 
and reasonable pride in my hard-won 
ability to get a line into a dehydrated 
child. (Of course, when I call such 
skills hard won, they were hardest 
won by the patients, the children on 
whom I practiced. In pediatrics, at 
least, pride of pro\\'ess is often accom 
panied by the guilt of knowing you 
have inflicted pain on a child.) 

As residents, we told humorous 
stories about high-ticket, entitled 
families who turned up in the emer- 
gency room demanding to have a 

child's blood test drawn by the depart- 
ment chairman (who probably hadn't 
done much scut recently) or refusing 
to let a lowly intern stitch up a lacer- 
ation. We knew we were the front- 
line people; we knew that in certain 
situations, we had made that impor- 
tant journey from initial fear and 
cluelessness to appropriately anxious 
skill. But of course, we also knew — 
as residents always know — that we 
were only residents, by definition 
beginners, unproven, not quite ready 
to be allowed out on our owm. 

One medical school classmate told 
me that, looking back, he suspects he 
was a much better doctor as a resident 
precisely because he was so anxious 
all the time, so deeply aware of the 
limitations of his own skill and 
knowledge. Once you start to behe\'e 
in yourself, he says, especially once 
you start to believe your patients 
when they tell you what a good doctor 
you are, then the pride hyperinflates 
and you lose touch with reality. He 
offered to direct me to studies that 
ha\'e sho\\'n that patients' estimates of 
their doctors' skills rarely correlate 
with outcomes. I did not, ho^^'eve^, 
want to introduce anything that 
smacked even faintly of evidence - 
based medicine into a discussion of 
medical egos, a topic that seems better 
suited for a kind of folkloric, if not 
operatic, approach. 

Bonfire of the Vanities 

How docs pride show up? Oh, let me 
count the ways! I remember my first 
beeper and how I wore it, ostentatious- 
ly, at parties, and gestured to\\'ard it, 
occasionally, in restaurants, to explain 
why I wasrit ordering wine. .And when 
it went off, I assumed that everyone 
around me was deeply impressed by 
this evidence of my importance — no 
doubt someone somewhere is very 
sick, I imagined them all thinking; 


it's a good thing they could reach the 
doctor! Over the years, of course, my 
feehngs changed; for one thing, many 
of my less savory adolescent patients 
carried beepers — at least back before 
cell phones — and for another, the 
chirp of the on-call beeper became 
just another dreaded interruption to 
family life. 

As a primary care pro\'ider, I ha\e 
taken tremendous pride in my long- 
term relationships with children and 
families. One delightful little girl 
became my signature patient. I had met 
her my first month at the health center, 
when she was a newborn. I took won- 
derful care of her as she was growing 
up, it seemed to me, and I regarded her 
as a li\-ing record of my time at the 
health center. Here she was, five years 
old — I had been in this job five years! 
I always asked for details about school; 
I boasted when she was placed in an 
advanced program; I bonded with her 
mother. I was part of her family, I 
felt, and everyone could recognize 
our connection whene\'er she came in 
for a checkup and ran to hug me. 

Then, when the girl was eight, I dis- 
covered I had been pronouncing her 
name wrong the whole time. I asked 
her mother why she had never correct- 
ed me. She just shrugged, as if to say, 
who can correct a doctor? I guess the 
lesson I learned was that yes, a right- 
ful and proper pride can come with 
knowing a patient and caring about 
the patient — but only if I actually take 
the time and trouble to pay attention 
to the patient, rather than to the 
drama of my own sensitivity. 

And yes, of course, a rightful and 
proper pride can come with being the 
one who makes the difficult diagno- 
sis, figures out the clinical puzzle. 
But many dangers come wrapped up 
in that pride — the danger of being 
thrilled with your own acumen in 
making a diagnosis that is actually 
terrible news for the patient, the dan- 


ger of losing sight of the patient alto- 
gether as you pursue the fascinoma, 
or, once again, the danger of begin- 
ning to think of yourself as the most 
important person in the story. I've 
done all those things, and I'm sure I'll 
do them all again. 

But Enough About Me 

As sins go, pride is the big one, the orig- 
inal of originals, the source of all the 
others. According to Thomas Aquinas, 
who knew one deadly sin from another, 
"inordinate self-love is the cause of 
every sin." And why would that be? 
Because "the root of pride is found to 
consist in man not being, in some way, 
subject to God and His rule." 

Hmmm — do you begin to see why 
medicine is saturated with issues 
involving pride? Doctors are steeped 
to our very core in trying to prevent, 
circumvent, and mitigate all the slings 
and arrows of outrageous fortune; we 
are the ones who think we can 
improve and even extend life. And, 
of course, sometimes we can. It's the 
pri\-ilege of the profession: the chance 
to make life better, ease pain, prevent 
complications, and sometimes even 
outwit death. And yes, of course we 
need to mix our sense of achieve- 
ment with appropriate humility — 
because, after all, the house always 
wins in the end. 

Somehow, though, being proud of 
your profession isn't really what peo- 
ple think of as sinful pride. Taking 
pride in something bigger than your- 
self — or in someone other than 
yourself — is not actually sinful; it's 
usually fine or good or even occasion- 
ally noble. It's perfectly reasonable to 
feel proud to see a patient live to enjoy 
another birthday or a graduation or a 
grandchild or a trip around the world. 

The sin of pride, I suspect, lies in 
being so proud of yourself that you've 
left no room for anyone else — not col- 
leagues, not even, in the end, patients. 
It's about losing track of all those other 
players in the glare of the spotlight 
that illuminates the single true star 
of the show and amplifies the din of 
thunderous applause. It's a profoundly 
insidious sin, since it's so easy to take 
pride in one's own humility, as I did 
when I was a medical student making 
fun of the arrogance of some attend- 
ings — or as I might be doing now, by 
pontificating at length, and in the first 
person, on the perils of placing oneself 
at the center of the story. ■ 

Pcrri Klass '86 will join New York University 
in September as a professor in journalism and 
pediatrics. The author of numerous hooks of 
fiction and nonfiction, she also serves as med- 
ical director of aliteracy program for children. 
Reach Out and Read, which medical students 
cleverly use to distract her while on rounds. 



hy Elissa Ely 


in a child who had many riches. But it was clear 
that other kids had more and better; simple 
possessions like two parents, or lavish posses- 
sions like two houses. One little girl's great- 
grandfather had invented the flush toilet; she 
had a spiral staircase in her bedroom, a sunken 
floor in her Uving room, and a movie crew for 
her sixth birthday party. 

Historically speaking, envy has been a grand 
force in the schemes of civilization. Morally 
speaking, you might not go so far as to call it a 
crime — it stops short of carnality or consti- 
tutional violation — but you also might not 
request it as the epitaph on your tombstone. 
Personally speaking, it has been nothing but a 
bellyache; there have been hundreds of causes, 
and all of them have hurt. 

These childhood abdominal twinges persist- 
ed in medical school. I envied easily and demo- 
cratically. Almost anything was worth coveting. 
For instance, at the back of the amphitheater, 
a row of women knit their way through the 

ru ha 



Curing envy may be as simple as refocusing your lens. 





One man was in the last phases of multiple sclerosis, often 
spasms. We were the same age and from similar backgrounds, 

preclinical years. They were quiet, 
capable, and unostentatious. Day 
after day, they worked on comphcat- 
ed pieces, digesting vast quantities of 
raw science at the same time. Once in 
a while, one of the knitters would halt 
production for a minute to make a 
note in her lap. Otherwise, their long 
bones clicked away, slipping pul- 
monary equations into cables and 
red blood-cell variants into rows of 
Fair Isle. Those serene elbows filled 
me with envy. Magnificent careers 
and sweaters were under construc- 
tion with the same ease. These women 
didn't seem to be paying for knowl- 
edge with blood like I was; they 
actually seemed to be enjoying them- 
seK'es. This was silly envy, petty envy, 
the envy of a six-year-old for her 
classmate's sunken living room — but 
still, it was stomach pain. 

The Other Side 

Since then I've had fleeting moments 
in which I've understood that envy is 
simple and real life is complicated. In 
the grips of lower-quadrant episodes, 
I sometimes realize that the Ii\'es I em'y 
are not always enviable. I worked in 
a state hospital during residency. 
Patients lived there for years; dis- 
charge summaries were novels 
because no one was getting better. 
One of the sickest women had undif- 
ferentiated schizophrenia. Her father 
was a famous psychiatrist. I had read 
his writing. I wanted his wisdom 
and, even more, his fame. 

The doctor was a rare but digni 
fied visitor. He never asked to look 
at his daughter's chart, never made 
medication suggestions, and never 
took us to task for our clear failures 
in his daughter's case. She was a 
mess, with her underwear outside 
her clothes and powder caked on her 
cheeks, talking in tongues and drag- 

ging a stuffed animal behind her. She 
approached his visits with ecstasy — 
everyone knew the dates and times 
of each anticipated arrival — and then 
destroyed them with some form of 
insane childishness. 

One day she was holding a cup of 
coffee when he arrived. The famous 
psychiatrist could not read the look 
on his daughter's white-powdered 
face. He was reaching to kiss her 
when she threw the coffee on his suit. 
He stood sadly, drippingly, in the day 
hall. In that instant, envy changed its 
physical state; what had been solid 
vaporized and rose away. He had 
nothing I wished for anymore. 

Another psychiatrist once told 
me a good story, which I hastened to 
steal. He himself had been someone I 
envied, until I realized he envied me, 
at \\'hich instant he lost his luster. But 
still, I took his story. He once went 
to a conference. The plenary speaker 
was an international authority on 
the topic — some enzyme, I think — 
and had devoted his career to its 
research. He was a man to be envied. 
When he came to the podium, my 
colleague saw he was thin and pale. 
It was a noble pallor; too many 
nights rewriting, too many commit 
tee meetings, too many textbook 
chapters, too much travel. What a 
price he paid for his fame! His com 
plexion reinforced his importance. 

My colleague turned to the man 
next to him. It was not anyone he 
knew, but he thought admiration 
might gi\'c the two of them something 
in common. He made a remark about 
the speaker, this outstanding scientist 
who had sacrificed so much — maybe 
family life, maybe health, God knows 
what else. A great man, for sure. 

The man next to him glanced up. 
"Never heard of him," he said. 

My colleague went home and 
gratefully kissed his children. 

It was a funny story — the stick 
hitting someone in the lotus position 
at the right moment. But it made its 
point. Ultimately, we wiU all dwell 
together, unrecognized, in dust. 

Deep Space 

Subtler forms of emy also exist and, if 
we are lucky, do us the profound fa\'or 
of educating us. When I was an intern, 
not one of my patients ever appeared to 
resent me for being well. Yet they must 
have felt it; each morning on rounds, 
we were a bed's distance and a world 
apart. One man was in the last phases 
of multiple sclerosis, often delirious, 
always incontinent, hard to under- 
stand, and racked by spasms. We 
were the same age and from similar 
backgrounds, separated by the simple 
fact that he was d)'ing and I was not. 

His iUness was umielding. Some- 
times he would emerge from deUrium 
into a lucid moment. When his wife 
was not there, ravenous for every 
intelhgible word, we chatted pleasant- 
ly He called me Little Doc. He didn't 
complain about the midnight blood 
draws, the intra\enous lines repeated- 
ly reinserted, the many tests without 
clear benefit. He understood they 
were feeble efforts at protection. Nor 
did he complain about the deepest 
difference between us. Why didn't he 
en\'y my health? He had the best cause 
of all for covetousness, but ne\er once 
pointed out this disparity. I would 
have been unable to forget it. Instead, 
I am unable to forget him. If grace 
occurs by example, let him be mine. 

We are all sinners. Life is short and, 
probably, only once. I admit I en\'y 
those who live it without compar- 
isons. The rest of us are only human, 
and hoping to be better. ■ 

Elissa Eh' '8S is a psxchiatnst at the 
Massachusetts Mental Health Center. 



delirious, always incontinent, hard to understand, and racked by 
separated by the simple fact that he was dying and I was not. 

1 ■' r 




i If / 



> {prideenvygreedwrathslothgluttonyllst} 

Sin of 



preparation — head down, trying not to screw up, trying to make it 
from one day to the next — that it is a shock to find yourself at the 
other end, with someone shaking your hand and asking how much 
money you want to make. But the day comes. Several years ago, 1 was 
finishing my eighth and final year as a surgical resident. Pd received 
a second interview for a staff position at Brigham and Women's 
Hospital, where I had trained. It was a great job — Pd get to special- 
ize in surgery for certain tumors that interested me, but Pd also be 
able to do some general surgery. ■ On the appointed day, I put on 
my fancy suit and took a seat in the wood-paneled office of the 
chairman of surgery. He sat down opposite me and then told me 
the job was mine. "Do you want it?" Yes, I said, a little startled. The 
job, he explained, came with a guaranteed salary for three years. 
After that, I would be on my own: Pd make what I brought in from 
my patients and would pay my own expenses. So, he \\^ent on, how 
much should we pay you? 

Why do the good doctors on television hospital dramas drive old 


cars while the bad ones wear bespoke suits? hy Atul GawANDE 


After all those years of being told 
how much I would either pay (about 
540,000 a year for medical school) or 
get paid (about S40,000 a year in resi- 
dency), I was stumped. "How much do 
the surgeons usually make?" I asked. 

He shook his head. "Look," he said, 
"you tell me what you think is appro- 
priate, and if it's reasonable that's what 
we'll pay you." He gave me a few days 
to think about it. 

People tend to gauge what they 
should be paid by what others are paid 
for doing the same work, so I tried 
asking \'arious members of the surgical 
staff. These turned out to be awkward 
com'ersations. I'd pose my Uttle ques- 
tion, and they'd start mumbling as if 
their mouths were full of crackers. I 
tried all kinds of formulations. Maybe 
they could tell me how much take- 
home pay would be if one did, say, 
eight major operations a week? Or how 
much they thought I should ask for? 
Nobody would give me a number. 

Most people are squeamish about 
saying how much they earn, but in 
medicine the .situation seems especial- 
ly fraught. Doctors aren't supposed to 
be in it for the money, and the more 
concerned a doctor seems to be about 
making money the more suspicious 
people become about the care being 
provided. (That's why the good doc- 
tors on television hospital dramas 
drive old cars and Uve in ramshackle 
apartments, while the bad doctors 
wear bespoke suits.) During our 
hundred-hour-week, just-over-mini- 
mum-wage residencies, we all take a 
self-righteous pleasure in hinting to 
people about how hard we work and 
how httle we earn. Settled into practice 
a few years later, doctors clam up. 

The Worth of a Pound of Cure 

Since the early 1980s, public surveys 
have indicated that two-thirds of 
Americans believe that doctors are 
"too interested in making money." "i'et 
the health-care system requires doc- 
tors to give inordinate attention to 
matters of payment and expenses. 

When I was going through medical 
training, a discouraging refrain from 
older physicians was that they would 
ne\'er ha\'e gone into medicine had the\' 
known what they know now. Many 
simply seemed unable to sort through 
the insurance morass. This was perhaps 

why a 2004 sun-ey of Massachusetts 
physicians found that 58 percent were 
dissatisfied with the tradeoff between 
their income and the number of hours 
they were v\orking; 56 percent thought 
their income was not competiti\e with 
what others earn in comparable profes- 
sions; and 40 percent expected to see 
their income fall over the next five years. 

William Weeks, a Dartmouth pro- 
fessor, has done a number of studies 
on the work life of physicians. He and 
his colleagues have found that, if you 
\iew the expense of going to college 
and professional school as an invest- 
ment, the payoff is somewhat poorer 
in medicine than in other professions; 
the annual rate of return by the time 
professional school graduates reach 
middle age is 16 percent per year in 
primary-care medicine, 18 percent in 
surgery, 23 percent in law, and 26 per- 
cent in business. Not bad, in any of 
these fields, but the differences are 
there. Physicians' incomes also tend 
to peak when they ha\'e been in prac- 
tice between five and ten years and 
then decrease in subsequent years as 
their willingness and abifity to work 
long hours wane. 

All that said, it seems churlish to 
complain. In 2003, the median income 
for primary-care physicians was 
5156,902. For general surgeons, Kke me, 
it was 5264,375. In certain specialties, 
the income can be a good deal higher. 
Busy orthopedic surgeons, cardiolo- 
gists, pain specialists, oncologists, neu- 
rosurgeons, hand surgeons, and radiol- 
ogists frequently earn more than half 
a rrdllion dollars a year. Maybe lawyers 
and businessmen can do better. But 
then most biochemists, architects, and 
math professors earn less. In the end, 
are we working for the profits or the 
patients? We can count oursehes lucky 
that we haven't had to choose. 

There are, however, those who do 
choose — and manage to earn consid- 
erably more than most. I talked to one 
general surgeon who had practiced at 
the same East Coast hospital for three 
decades. His schedule was not unduly 
hea\y, with office hours from nine- 
thirty to three-thirty just one day a 
week and only about six operations 
a week. I asked how much he earned. 
"Net income?" he said. "About one 
point two million last year." 

I had to catch my breath. He'd made 
more than a miUion dollars e\ery year 



Most people are squeamish about saying how much 
they earn, but in" medicine the situation seems especially 
Taught. Doctors arerit supposed to be in it for the money. 


.«■:»■■ f ; 

for at least the past decade. He was 
perfectly aware of the reaction. "I think 
doctors shortchange themseh'es," he 
said. "Doctors are working for fees that 
are similar to or below plumbers' or 
electricians'" — professions that, he 
noted, don't require a decade of school 
and training. He doesn't see why doc- 
tors should let insurance companies 
dictate their compensation. So he 
accepts no insurance. If you want to 
see him, you pay cash. 

The fees he charges are what he 
finds the market will bear. For a 
laparoscopic removal of the gallblad- 
der, insurers will pay surgeons about 
$700. He asks for S8,500. For a gastric 
fundoplication, an operation to stop 
severe reflux of stomach acid, insurers 
pay Sl,100. He charges S12,000. He has 
had no shortage of patients. 

It's not clear how easily others 
would rephcate his success. After all, 
he works in a metropoUs, where many 
people can afford his fees. He's also 
something of a star in his field. 

But suppose I did what he did — 
refused to deal with insurance and 
charged what the market would bear. I 
would not make millions, but I could 
make much more than I otherwise 
would. I'd avoid all the insurance has 
sles, too. Srill, would I want to be a doc 
tor only to those who could afford me? 

Why not? the surgeon was asking. 
Everyone squeezes us to make money, 
he said — everyone from the supply 
companies we pay to the insurers who 
pay us. In his view, doctors need to 
understand that we are businessmen — 
nothing less, nothing more — and the 
sooner we accept this the better. 

His position has a certain bracing 
clarity. Yet, if this is purely a service- 
for money business, if doctoring is no 
different from doing oil changes, why 
choose to endure twelve years of med 
ical training, instead of, say, two years 
of business school? I still beUeve that 
doctors remain fundamentally moti 
vated by the hope of doing meaningful 

and respected work for societ)^. Hence 
the responsibUity most of us feel to 
take care of people even when their 
insurers exasperate us, or when they 
ha\e no insurance at all. If we fail ordi- 
nary people, then the notion that we 
do something special is gone. 

The Price Is Slight 

Physicians" after- expense incomes are 
a fairly small percentage of medical 
costs. But we're responsible for most of 
the spending. For the patients I see in 
the office in a single day, I prescribe 
around $30,000 worth of speciaUst con- 
sultations, surgical procedures, hospital 
stays. X-ray imaging, and medicines. 
And how well these services are reim- 
bursed inevitably affects how lavish 
I can be in dispensing them. This is 
where income becomes politics. 

Ele\'en years ago, I received the bill 
for the heart surgery that saved my 
son's life. The total cost, it said, was 
almost a quarter-million dollars. My 
pa)Tnent? Five dollars — the cost of the 
copay for the initial visit to the emer- 
gency room and the doctor who figured 
out that our pale and struggling boy 
was suffering from heart failure. If my 
wife and I had needed to, we would 
ha\'e bankrupted ourseh'es for him. But 
insurance meant that all anyone had to 
consider was his needs. It was a beauti 
ful thing. Yet it's also the source of what 
economists call "moral hazard": with 
other people paying the bills, I didn't 
care how much was spent or charged to 
sa\'e my child. To me, all the members of 
the team deser\'ed a million doUars for 
what they did. Others were footing 
the bill — so it's left to them to question 
the price. Hence the adversarial rela- 
tionship doctors ha\'e with insurers. 

Given the politics, what's striking 
is how substantial medical payments 
have continued to be. Physicians in the 
United States today remain better 
compensated than physicians any- 
where else in the world. Our earnings 

are more than se\'en times those of the 
average American employee, and that 
gap has grown over time. (In most 
industrialized countries, the ratio is 
under three.) This has allowed Amer- 
ican medicine to attract enormous 
talent to its ranks and kept doctors 
willing to work harder than members 
of almost any other profession. 

At the same time, the politics of 
health care has shown little concern 
for the uninsured. One in seven Amer- 
icans has no coverage, and one in three 
younger than sixty- five will lose cover- 
age at some point in the next two 
years. These are people who aren't poor 
or old enough to qualify for govern- 
ment programs but whose jobs aren't 
good enough to provide benefits, 
either. Our byzantine insurance sys- 
tem leaves gaps at every turn. 

A Healthy Curiosity 

A few days after the chairman of 
surgery offered me the job, I returned 
to his office and named my figure. 

"That'll do fine," he said, and we 
shook hands. Now I am the one who's 
too embarrassed to say what I earn. 
We talked for a while afterward: about 
how to fit research in, how many 
nights I'd have to be on call, how to 
keep time for my family. The prospect 
of my new responsibilities filled me 
with both exhilaration and dread. 

As the meeting was ending, though, 
I realized there was one final impor- 
tant question I had not brought up. 

"What are the health benefits like?" 
I asked. ■ 

Atul Gawande '94 is a surgeon at Brigham 
and Women's Hospital an assistant profes- 
sor of surgery at HMS, and a staff writer 
for The New Yorker. His upeoming hook. 
Better: A Surgeon's Notes on Perfor- 
mance, is slated for publication hy Metro- 
politan Books in the spring of 2007. This 
essay was adapted from an article that 
appeared in The New Yorker. 






ci\c\ne? by A Lie £ ^ 



the time in thought, word, and deed, and stories of irate 
prophets fill the Bible. Would it be evil, I wondered, to 
write that anger isn't so bad? I asked Michael Suarez, a 
friend and a Jesuit, for guidance. Michael pointed out 
that, in the medieval conception of hell, anger was the 
only sin treated surgically, with dismemberment. He 
went on to explain, though, that only excessive anger is a 
sin. "You go, girl," he said. 

! Once I had anger's theology straightened out, I could turn to 
its neurology. Early wrath researchers studied cats and found 
that stimulating a feline's medial hypothalamus prompted § 
it to assume a rage posture: spitting, arched back, bottle- | 
brush tail. Stimulating its lateral hypothalamus, on the other I 
hand, triggered a predatory, sHnky mouse-killing posture, i 


A particularly forceful mentor in medical school once 

r explained to me, "I consider everything that 

to be mine. And I decide what is nailed down." 

Human brains maintain this distinc- 
tion between defensive and offensi\'e 
aggression. One circuit guides us when 
something we consider ours is threat- 
ened: our corner office, our dignit}'. The 
other kicks in when we want some- 
thing not yet ours; a scientific discov- 
ery, a tricky patient's comphance. Of 
course, many factors influence what 
we define as ours. As a particularly 
forceful mentor in medical school once 
explained to me, "I consider e\'er}thing 
that isn't nailed down to be mine. 
And I decide what is nailed down." 

We think of anger as the emotional 
component of aggression. In the basic 
biological sense, aggression and its 
emotional drive are so integral to our 
motivational system that it is difficult 
to imagine life without them. Mate- 
seeking is a form of aggression, even in 
the healthiest of us. That link between 
love and war is being found at the 
molecular level; The laboratory of 
HMS neurobiology professor Edward 
Kravitz recently showed that the 
same gene controls both aggressive 
and mating behavior in fruit flies. 
Indeed, love is not the opposite of 
aggression; abulia — a lack of desire 
and motivation — is. While anger is 
often irrational and counterproduc- 
tive, so can lo\'e be, as when a patient 
remains devoted to an abusive spouse. 

Although emotions are irrational, 
removing all emotion turns out to be 
even more so. One of the revolutions 
in modern affective neuroscience has 
been to show that patients who can 
not feel emotions are terribly impaired 
at normal decision making. They vac- 
illate, fiddling while Rome burns. 

Even if we narrowly define anger as 
the desire to inflict pain — which we 
shouldn't, because they aren't equiva- 
lent — there is an unfortunate sense 
in which that desire may be useful to 
physicians. A particular interest in 
pain can drive de\'otion to medicine, 
and doctors must often hurt to heal. A 

study from the 1950s, the golden age 
of career profiling, showed that physi- 
cians score higher than the general 
population on indices of sadomaso- 
chism. (The masochism part is espe- 
cially useful during residency) 

The Shapes of Wrath 

One of anger's most troublesome 
aspects is its contagion. All emotions 
are infectious, but escalating anger is 
more likely than love, fear, or disgust 
to trigger physical violence. One 
approach to blocking this escalation 
draws on Freud's reser\'oir and cathar- 
sis theory. It proposes that unex- 
pressed anger builds up and that talk 
therapy can discharge it more safely 
than action can. 

One of my patients, a writer, would 
seem to exemplif)' this. He is generally 
polite when hospitalized — at the 
most, he avoids an annopng doctor by 
pretending to be in a coma until the 
doctor leaves. After one such pseudo- 
coma he half-opened an eye and asked, 
dryly, "Why do I write such angry 
books?" The stock answer, of course, 
would be that he does so to vent the 
anger that his good manners suppress. 

There is little scientific evidence, 
however, that expressing our wrath 
lessens it, except in those satisfying 
cases where it helps us get what we 
want. In most situations, studies show- 
that venting anger merely heightens it, 
both in our ri\'als and in ourseh'es. 

The biological basis of this emo- 
tional contagion is the mirror neuron 
system, a fascinating group of move- 
ment-control cells that fire when we 
perform an action and when we see 
someone else do the same action. 
Through these cells' mirroring func- 
tion, witnessing an action also 
increases our own tendency to mimic 
it. Because performing an emotional 
gesture can induce the sensation itself, 
seeing another person's anger can make 

us feel it. This is the neurological mech- 
anism by which rage in deed spawns 
rage in thought. 

Mirror neurons have a special 
importance for medicine because their 
emotional contagion underUes empa- 
thy. The link between empathy and 
behavioral imitation would suggest 
that empathic people are more imita- 
tive. And that is true, at least for ges- 
tures. People who score high on tests 
of empathy are also much more likely 
to unconsciously imitate others' emo- 
tional gestures in a conversation, even 
their emotionally neutral gestures. 
This finding suggests a simple test of 
compatibility: watch how often the 
other person rubs his or her nose when 
you rub yours. 

Empathy's roots in simple imitation 
don't prevent it from achieving great 
complexity. Anger and many other 
high-level factors modulate mirror 
neuron actixlty. Functional magnetic 
resonance imaging shows that the 
mirror neuron area is active when one 
person witnesses another getting a 
painful electric shock. A recent 'Sature 
paper showed that the mirror neuron 
activity of someone observing the 
shock significantly decreased when 
the person receiving the shock had 
just cheated the observer at an eco- 
nomic game. Instead, reward- area 
activity increased — but only when the 
observer was male. Female observers 
had little decrease in mirror neuron 
activity and often reported that the 
cheater did not deser\'e the shock. 

As this experiment indicates, anger 
is the emotional response to what 
we perceive as an intentional injury. 
The first-order response to anger is 
an impulse to take action, call it "jus- 
tice" or "vengeance." If we have time, 
however, to consider our interests 
and self-image we may choose other 
responses. We feed the child after she 
has bitten us; we offer the abusive 
patient a way to save face and accept 



isn't nailed down 


our suggestions. These are strategic, 
not mirroring, choices. 

Mirror neuron hanction would seem 
to make a counterintuiti\'e prediction 
about expressing therapeutic empa- 
thy toward angry patients. Given 
anger's contagion, when a patient is 
raging, wouldn't mirroring that anger 
make things worse? Not if done right. 
Staying calm nom'erhally denies the 
anger and may make the patient try to 
communicate the emotion e\'en more 
strongly. The trick is to express 
patients' anger o\'er their own sense of 
injury rather than your anger toward 
them. Leston Havens, HMS professor 
of psychiatry, has pointed out how 
much more effective it can be to 
pound the table and bellow, "How 
infuriating!" than to try sweet-talking 
someone out of his or her anger. Once 
the doctor and the patient are on the 
same resonant frequency, it's easier for 
the doctor to decrease the amplitude 
of the patient's wild oscillations. 

Hell Hath No Fury 

Turning from anger in medicine to 
anger medicine brings us to another 
twentieth-century holdo\er: the behef 
that angry, type A men are more like- 
ly to develop heart disease. Recent 
research shows, howe\er, that type A 
personality does not confer much car- 
diovascular risk. The ones at risk are 
those with type D personality — 
depressed and passively hopeless. 
Moreo\'er, while aggression correlates 
with higher death and injury rates 
among poor men, it correlates with 
greater success among high-status 
men. Anger is a tool; it works in some 
situations and not in others. Notably, 
it is a much healthier solution for peo- 
ple with power. That's why more doc- 
tors yeU at nurses than the reverse. 

Could it be that nurses yell less 
because they're more likely to be 
female? It's true that part of men's 

higher aggression comes from the 
effects of circulating testosterone. 
Lawyers have shown us that this 
holds for women too: After w inning a 
trial, female prosecutors experience a 
rise in testosterone levels. Judiciously 
apphed testosterone gel would help 
nurses yell more, if at some cost of hir 
sutism and acne. Comersely, gerontol- 
ogists sometimes gi\'e demented elder 
ly men estrogen to make them less 
aggressive toward others. 

Independent of hormones, though, 
a cost-benefit analysis shapes women's 
decreased aggression. As women tend 
to be smaller and lower in status, it 
is more often to their advantage to 
conciliate. When experiments place 
women in situations where they are 
reliably rewarded for their aggres- 
sion, however, they quickly play as 
aggressively as men. It's just that 
daily life, whether in the hospital or 
elsewhere, does not usually present 
such situations. 

One of my own experiences sug 
gested that those situations occurred 
more often than I thought. Several 
years ago, on my return from a neurol- 
ogy meeting, I found myself in an air- 
port snarl with Uttle hope of getting 
home that night. As I stood wanly in 
an endless counter line, my depart- 
ment chief, Anne Young, strode past, 
scowhng. "I can't wait in this hne!" she 

said to the man behind the counter. "I 
ha\'e to get back to Boston right now'." 

He immediately issued her a new- 
ticket and sent her to another gate 
that was loading smoothly. I realized 
the counter guy had no idea she was 
the president of the Society for Neuro- 
science. She's not all that tall, nor was 
she — sorry, Anne — imposingly dressed. 
So I set my brow in a scowl, strode 
up to the counter, and imitated her. 

The counter guy smiled appeasing 
ly and put me on the same plane. I 
e\'en got a free cab ride from the air- 
port with .-Vnne. I decided to take this 
as e\idence that God condoned my 
anger. In the cab, though, Anne argued, 
"Alice, I wasn't being aggressive, 
just... assertive." 

"Didn't you want to punch some- 
one, maybe the counter guy, just a bit?" 

"Well sure! But that was just a 
Uttk anger." 

There you go — all we have to do is 
to a\'oid excessive anger. And figure out 
who gets to decide what is excessi\'e. ■ 

Alice Flaherty '94, a neurologist at Massa- 
chusetts General Hospital is author of The 
Midnight Disease: The Dri\e to Write, 
Writer's Block, and the Creative Brain. 
Her first children's hook. The Luck of the 
Loch Ness Monster: A Cautionary Tale 
of Picky Eating, is scheduled for publica- 
tion by Houghton Mifflm m 2007. 



Sometimes slacking off con be the best medicine of all. 

i 'I_,DILE 





innocuous, if not downright salubrious. While the 
perilous excesses of lust and gluttony are obvious, sloth 
seems merely an exaggerated form of relaxation, which 
is supposed to be good for us. Envy, anger, and greed 
dilute down to jealousy, resentment, and selfishness, 
none of which promotes healthy blood pressure the way 
repose does. And while pride carries certain positive 
connotations, even that petty self- congratulation doesn't \ 
feel as good as napping in a hammock all afternoon. ; 

hy Rafael Campo 

Sadly, the medical profession has become rife with intellectua 
the work of our stethoscopes and skulk about on morning 

sloth doesn't even sound terribly men- 
acing. It rolls off the tongue almost 
effortlessly, which nearly makes it an 
example of onomatopoeia, a word that, 
by contrast, takes great effort to pro- 
nounce and hardly seems any more \ir- 
tuous. For poets, whose interest in the 
sound of words is rivaled only by 
our appreciation for relaxation and 
hammocks, sloth is also rich in rhyme 
words, like "froth," "broth," and 
"troth," or — for the chiefly British pro- 
nunciation — "growth" or "oath." While 
I can't say I've used all these rhymes in 
my own poetry, this is not for lack of 
tr)'ing; I'm knowTi for my frequent and 
subtle use of words that sound like 
their meanings. 

Poets are also fascinated by the ety- 
mologies of words, which might seem 
contrary to our reputation for being so 
stress-averse. Why, I couldn't help won- 
dering, did the Bullcfin's editor ask me to 
WTite on what Evagrius of Pontus, upon 
first arriving at his short list of partic- 
ularly notable human failings, called 
"acedia"? For those of you too lazy to get 
up off the couch, fire up your laptops, 
and do a Google search, "acedia" has its 
roots in the Greek word akedeia, which 
translates roughly as "not to care." 

It is unfortunate that "sloth" is also 
the name we've given to one of the 
least appealing species on the planet; 
defenders of the sloth, however, are 
quick to remind us that these homely 
creatures possess a sweet and gentle 
nature. They are more likely to die 
under the wheels of a car driven by a 
stressed-out human than of the mal- 
adies that plague overachievers, such 
as stroke and bleeding ulcers. 

I suppose I must concede that a 
medical downside to sloth does exist 
beyond the perils of a sedentary life- 
style. It pains me to witness examples 
of the bad kind of sloth on hospital 
wards, and by this I don't mean the 
room after room of people lying Listless- 

ly in bed all clay. (Sloth isn't so terrible 
when we call it "recuperation," is it?) 

I have felt dismay whenever the 
notes of attendings have simply regur- 
gitated the physical exam findings 
that the third-year medical students 
have written. I also detest all those 
unexacting and sometimes confusing 
abbreviations, such as "VSS," which 
makes me think of the age designa- 
tions on bottles of cognac; "A&Ox3," 
which resembles the string of cuss- 
words that fly from the mouths of car- 
toon characters; and "ARDVTCVT" — 
God only knows what it means, but if 
written in a cardiology consultant's 
note, it's probably lethal unless one 
administers IG IV MG STAT. 

Sadly, the medical profession has 
become rife with intellectual slackness. 
We rely on echocardiogram machines, 
for example, to do the work of our 
stethoscopes. And we skuUc about on 
morning rounds hoping not to be spot- 
ted by patients' family members, whose 
questions wiU only prolong the execu- 
tion of our tasks — if the institution 
hasn't already hired hospitahsts to per- 
form even this basic function for us. 

It's not as if we're using all our free 
time to read the New England journal of 
Medicine cover to cover (we have pumal 
Watch for that) — nor are we bettering 
ourselves by reading poetry or watch- 
ing the History Channel. And we have 
the nerve to accuse our patients of 
sloth, as if the association between 
physical inactivity and obesity could 
be any worse than the association 
between years of medical training and 
an ignorance of the word "acedia"! 

It was my own ignorance of a word 
that once led me to mistake convales 
cence for indolence. I was a brand- 
new third-year medical student on 
the surgery service of a Boston hos- 
pital. Mrs. C. was a pleasant older 
woman whose inflamed gallbladder 
we had successfully remo\'ed without 



slackness, as we rely on echocardiogram machines to do 
rounds hoping not to be spotted by patients' family members. 

complication several days earlier. 
Charged with sending her home, I 
was eager to see her resume her regu- 
lar activities. So, armed with a clip- 
board full of discharge instructions 
and triphcate forms, I marched into her 
room to find her seated in her bedside 
chair, her hospital gown billowing 
out around her and a somewhat 
uneasy look on her face. I had noticed 
she seemed to spend a great deal of 
time in that chair, and I suspected she 
was a slacker in need of firm treat- 
ment to get her active again. 

Before she could offer any objection, 
I launched into my spiel what actixities 
she could and could not undertake, a 
detailed list of her discharge medica- 
tions, a nuanced explanation of the 
need for exercise to combat the ills of a 
sedentary lifestyle. As I rambled on, she 
looked more and more uncomfortable. 
Sensing she might still harbor reserva- 
tions about getting back on her feet, I 
reassured her that she would be fine, 
and indeed that she was far better off at 
home, reminding her that the hospital, 
despite the doting nurses and h-ec[uent 
dehveries of free food, was actually a 
dangerous place. By now, her face had 
turned beet-red, almost purplish, 
and so I decided, after a long breath, 
to allow her the chance to speak. 

"Young man," she thundered, "I'm 
in the middle of a movemcntr 

Suddenly I realized two things. 
First, what I had assumed was an 
amply proportioned easy chair was 
actually what the nurses had been 
calling a commode, and second, what 
they meant by "commode." The reader 
should now understand my instinct to 
fight sloth and discover the meanings 
of words, especially unfamihar ones. ■ 

Rafael Campo '92 practices internal medicine 
at Beth Israel Deaconess Medical Center in 
Boston. No sloth himself, he has published 
numerous hooks of poetry and essays. 







ill. t 1 .'il) ■; I :\'',- ! 




hy William Ira Bennett 




pains me most is my inability to abolish the sin of 
gluttony from the canon. Almost 25 years ago, when 
Joel Gurin and I finished writing our book ThcDictcfs 
Dilemma: Eating Less and WeighingMore, I beheved we had 
a shot at reducing the number of deadly sins, at least 
in secular terms, from seven to six. We made a pretty 
good case, I thought, that gluttony simply doesn't 
exist, that the very notion of "overeating" verges on 
the nonsensical, and that any serious approach to 
weight control would call for a radical rethinking 
of the way the body manages its energy stores. 

The waistline wars pit virtue against vice while 
ignoring the objections of science and logic. 


obesity is still almost universally understood, even by 

private moral matter. The guilt of the fat is reheved 

by accusations directed at fast-food joints and soft-drink 

By 1981 a body of evidence was 
emerging in the scientific literature 
that fat is not simply an accidental 
accumulation of calories resulting from 
ill-informed or self indulgent eating 
beha\ior. Rather, energy stores are sub- 
ject to intensive management by the 
body, and eating behanor is a response 
to the body's demand for fat, not an 
independent variable, and certainly not 
the independent variable. Fat stores 
may vary in amount and distribution 
over time, and they can sometimes be 
consciously modified, but fat has a life 
and a mind of its own. Joel and 1 laid 
out the best argument we could — 
based on evidence that had been accu- 
mulating for four decades — that the 
brain and the waistline are in intimate 
communication with each other and 
that the brain acts to match energy 
stores with a "setpoint" \'alue that is 
determined by genetic endovvTnent and 
modified by environmental influences. 

What was missing from our set- 
point argument at the time was clear 
evidence that the brain had any effec- 
tive means of measuring body fat 
stores. As one distinguished HMS 
alumnus said to me, "You don t have a 
smoking gun." We didn't, although 
there was already a good deal of 
smoke in the room. It would be 
another decade before the first gun, 
leptin, was discovered in what has 
since proved to be a large arsenal of sig- 
nals informing the brain about energy 
balance in the body The Ust is long, and 
the names are sometimes exotic. They 
include ghrelin, obestatin, resistin, 
melanocyte- stimulating factors alpha 
and beta, interleukin-6, tumor necrosis 
factor alpha, and my all-time favorite, 
Foxc2. Quite apart from the fact that 
Foxy Too sounds like an Internet 
come -on, this molecule is described 
as being a "winged helix forkhead 
transcription factor." Its expression is 
stimulated by high- fat diets. So if obe- 
sity really is a battle between good and 

evil, the movie will have to show an 
army of fork- headed helices flying in 
formation over a crater of boiling oil. 

The Weight of the Evidence 

Delicious bits of evidence against 
gluttony as an explanation for obesit)' 
accrued in the 1950s and 1960s when 
Ethan Allen Sims, a distinguished 
endocrinologist at the University of 
Vermont, set out to study the effect 
of intentional overeating on human 
volunteers. Sims found it difficult to 
locate a population that could meet his 
experimental requirements. College 
students couldn't sit still long enough 
to gain weight, and negotiations with 
a monastery had fallen through. 

Sims was finally able to work out 
a deal with the inmates of a Vermont 
prison, who should have been ideal for 
the task. These were, after all, people 
for whom a propensity to heedless 
self-indulgence had already been 
estabhshed in court and who ought to 
have been delighted at the prospect of 
eating half a dozen banana sphts in the 
course of a day while lounging around 
in striped pajamas. Yet one of Sims's 
discoveries from this research was that 
overeating to gain weight proved both 
physiologically and psychologically dif 
ficult for the subjects, many of whom 
wanted out of this trial. 

Joel and I also knew about critical 
experiments leading, decades later, to 
the discovery of leptin, but much to our 
eventual regret we decided they were 
too difficult to describe and left them 
out of our book. In his brilliant and 
quirky way, Douglas Coleman at the 
Jackson Laboratory in Bar Harbor, 
Maine, had demonstrated that a circu- 
lating factor profoundly influenced 
accumulation of body fat in mice. Cole 
man showed this bv stitching together 
two mice — one genetically obese but 
otherwise identical to another of nor 
mal weight — so that they shared a 

common circulation. This procedure 
led to profound changes in the obese 
mouse; it lost weight. A factor in the 
bloodstream of the normal animal had 
apparently "signaled" its twin that 
enough fat was already present on its 
body — no need to acquire more. Yet, 
matched to an obese mouse with a 
different mutation, the normal mouse 
would dwindle to death. In this case 
the normal twin was falsely informed 
that it had too much fat on its body. 

Even without this tale of two 
rodents, we thought we had made a 
tidy, readable, and even amusing case. 
If nothing else, w^e could offer a theor)' 
for the relentless failure of diet plans 
(and the equally relentless appearance 
of new ones rising from the trash heaps 
of Scarsdale and Beverly Hills). 

What we didn't fuUy appreciate was 
the fact that the oral stage of human 
development is the first and by far the 
most persistent. For perfectly good 
evolutionary reasons a mammal's ner- 
vous system is perched immediately 
above its food-intake apparatus. If a 
problem can be understood in terms 
of appetite, it will be. Thus, otherwise 
subtle thinkers descend to stunningly 
simplistic vvorldviews when the sub- 
ject is adipose. Indeed, Joel and I lost 
the battle for our own title, which our 
publisher selected hoping to sell more 
books by including the word "diet." 
We wanted to call our book ThcMattcr 
of Fat. which probably would have 
reduced its merely modest sales to the 
downright microscopic. 

We also disregarded how attached 
people are to guilt. They have an insa- 
tiable appetite for it. Given the oppor- 
tunity, people will take guilt over 
almost an)' other state of mind. I say 
this with misgiving, as common sense 
suggests blame would be the popular 
choice. Nevertheless, guilt is the win 
ner. Obesit)' is stiU almost universally 
understood, even by the obese, as a pri- 
vate moral matter. The guilt of the fat is 



the obese, as a 
only occasionally 

relieved only occasionally and momen- 
tarily by accusations directed at large 
industries, as when fast-food joints and 
soft-drink manufacturers are blamed 
for the international epidemic of obe- 
sity. Parenthetically, the petroleum 
industry, which is at least as imphcat 
ed in this so-called epidemic, is rarely 
accused of causing weight gain. I believe 
there are t\vo reasons for this. We relate 
to our cars with our hands (implication: 
mastery) instead of our mouths (implica- 
tion indulgence). Of course, oilmen also 
appear to be e\'en slicker than cigarette 
manufacturers when their products 
come under scrutiny. 

After the genital organs, body fat is 
the tissue with the highest level of 
moral content and hence the highest 
associated level of guilt. (Biomedically 
speaking, "moral fiber" is a complete 
nonstarter.) I suppose one reason for 
our attachment to guilt is that it is so 
intimately Unked to hope and the fan- 
tasy of "will power." By a somewhat 
perverse reasoning process, guilt 
impUes the possibihty of salvation or, 
better yet, a smaller dress size. 

I cannot deny the evidence that 
weight may be controlled, at least to 
some degree, by restricting food intake. 
Survivors of concentration camps or 
the South Beach Diet are, at least for 
a while, thinner than before. Whether 
it is possible to use these methods of 
weight reduction without inducing 
post-traumatic stress disorder is, I 
think, an open question. Whether the 
weight loss will outlast the trauma is 
equally open to study 

Eating Your Words 

After The Dieter's Dilemma was pub- 
lished, it enjoyed a brief period of 
media attention. I am, to this day, 
grateful that this part of the experi- 
ence came to so httle. On a photo shoot 
arranged by People magazine, Joel and 
I were taken to a local park and posed 

in running shorts with our mouths 
wide open at either end of a six-foot 
submarine sandwich. The editors 
killed the article, which was a far bet- 
ter outcome than if it had been pub- 
hshed and 1 had had to kill myself. 

As our national tour went into its 
second, declining week, I found myself 
on a radio talk show somewhere in 
Canada. The host, a hearty, bluff man, 
was an exception to the rule of guilt. 
He was happy to blame his wife — and 
all wives everywhere — for spousal 
obesity. It was actually a nice twist of 
sociobiological thinking on his part: 
women make their husbands fat to 
make them unattractive to other 
women and thus faithful to themseh'es. 
Nothing I could say would derail him 
from his pursuit of this conjugal point. 

Perhaps the happiest outcome, for 
me, from the pubhcity phase of The 
Dieter's Dilemma was that I eventually 
learned to say, with perfect comfort, 
"No, I have no interest whatsoever in 
appearing on Oprah." I would not have 
minded becoming famous, much less 
becoming rich. But what I took away 
from my few television appearances 
was that 15 minutes sUghtly underesti- 
mates the duration of television 
fame — and significantly o\'erestimates 
the abihty of viewers to remember the 

reason for fame. A day or two after one 
appearance a stranger came up to me 
with a pleasant smile and said, "I saw 
you on TV the other day! You were 
talking about . . . something." 

Joel and I believed with near- 
apostohc fervor that we could release 
our readers from the sin of gluttony. 
But we were thinking of a sin as some- 
thing one does. Our readers, perhaps 
correctly, took our message as Calvin- 
ist; A sinner is something you are. We 
had inad\'ertently moved the doctrine 
of the elect to the waistline. And so we 
managed to turn off two kinds of read- 
ers. The overweight wanted to beheve 
they had made themselves fat, as this 
held out the hope of repentance, salva- 
tion, and better sex. Our thin readers 
weren't content to believe that their 
figures were the outward and visible 
signs of genetic grace and often deeply 
resented our efforts to deprive them 
of credit for their virtuous ways. And 
that is how Joel and I became prophets 
without profit. ■ 

William Ira Bennett '68, who practices 
psychiatry in Cambridge, Massachusetts, is 
editor-in-chief of the Harvard Medical 
Alumni Bulletin. Since coauthoringThe. 
Dieter's Dilemma with Joel Gurin (Basic 
Books, 1982), he has gained 30 pounds. 



Passion marksihe times in a 

f ^ 


Lust me, 
Fm a doctor 

Dhysician's life— and adds life to his times, hy STEPHEN BERGMAN 


the risk-benefit ratio may well be overblown. The six other 
deadlies are clearly iniquitous. But lust? 

Think about it. Lust itself, v^dthout an object, is pretty vague 
and rarely dangerous — except, perhaps, when spoken aloud by 
U.S. presidents, as when Jimmy Carter fessed up to the lust in his 
heart or Bill Clinton disavowed his lustful acts. George W. Bush, 
on the other hand, seems boyishly lustless. In the bizarre Amer- 
ican national calculus, the lust for a thong can nearly bring down 
a commander in chief, but the lust for oil and empire and revenge 
that strews bloodied bodies in its wake cannot. 

While a doctor's "lusty" sex life may be healthy, lust can easily 
turn to savagery and shame, blame and perjury, and then — 
bingo! — there goes the license to practice. But let's wait on sex 
and examine first some of the other objects of lust in medicine. 



Given the senseless pressures we faced, sex was 
^ one of the two ways we affirmed that we weren't 

I dying or dead, but rather young and healthy and alive. 

The Lust for Gross Anatomy 

I attended my first day of dissection at 
Harvard Medical School with some 
trepidation. I had spent the previous 
three years in Oxford, England, eating 
strawberries and cream on the lawn, 
and now I was staring at cada\'ers and 
sniffing formaldehyde in the base- 
ment. My reaction to this scene was 
not the usual faintness of heart, but 
rather an epiphany, with a little inner 
voice whispering: "Maybe Vietnam 
would have been better after all?" 

My partner and I were instructed 
to dissect the brachial plexus. He, a 
budding surgeon, snatched up the 
knife and began to hack away with a 
kind of missionary zeal at the jungle 
of muscles and nerves. I watched. He 
could not find the brachial plexus. The 
instructor came over. He was a thin, 
fit, lustful Brit. 

"We carit find the brachial plexus," 
moaned the surgeon- to-be. 

"Maybe he didn't have one," 
added I. 

The instructor looked at the 
corpse's muscular arm, shrugged dis- 
dainfully, and, with a kind of glee, 
poked his nose into what had once 
been an intact armpit. He straightened 
up and said, triumphantly, "You stupid 
bastards, you chopped it up into lin 
guini!" Then he dug into the goo of 
the other armpit. My memory has 
him working away while whistling a 
salacious ditty popular during World 
War II: "Monday night me 'and was 
on 'er ankle, Tuesday night me 'and 
was on 'er knee." The guy lusted after 
that plexus. The song ended with, "I 
don't want to join the army! I don't 
want me gonads shot away-y-y..." 

The Lust for on Organ 

In the spring of 1970, the student 
resistance movement to the Vietnam 

War had heated up and we'd learned 
that the Ohio State National Guard 
had killed four protesting students 
at Kent State University. Many uni- 
versities went on strike, and stu- 
dents at HMS needed to decide 
whether to join in. We first-years 
were about to begin the Kidney 
Block, and so we called a meeting to 
debate the issue. Speeches were 
given on both sides: "If we go on 
strike, we'll never learn the kidney!" 
versus "The hell with the kidney! 
This is more important." 

We went on strike. I never learned 
the kidney. In my novel The House 
of God the kidney is only vaguely 
described as an organ floating some- 
where between the back of the neck 
and the back of the knee, and one of 
the villains is a kidney doc. This 
character lusts after the kidney — 
lusts, in fact, for any failing organ 
with which he can "teach [his] boys 
medicine." Lusts more, alas, for the 
organ than for the organism that con- 
tains it. Oblivious to the real human 
stuff, he inadvertently provokes his 
students to treat humans inhumane 
ly, making a hash of the internship 
experience. Thus, one of the bad 
traits of lust: it may get in the way of 
good relationships and may make 
other people's lives miserable. 

The Lust for Cash and Power 

A wise teacher once told me: "The 
hearts of ambitious people dry up." 
All around us in medicine, especially 
in large academic settings, one can 
see the gleam in the eye of a young 
man or woman ogling the next rung 
up, slurping the next slurp up that 
big luscious ice cream cone and paus- 
ing only to intone: "Publish or per- 
ish," or "Let's go look at that liver in 
Room 1102," or "The only problem 
\\ith learning the name of one more 

patient is that you forget the name of 
one more protein." 

A friend with cancer recently told 
me that while at the National Insti- 
tutes of Health he felt he was being 
treated as Lab Rat Number 178. My 
own profession, psychiatry, may be 
one of the worst examples of the lust 
for cash, power, and academic star- 
dom. I chose the field because I 
thought it was one of the more 
humane areas of medicine. "Talk ther- 
apy," when it is the patient's and doc- 
tor's shared journey through suffering, 
can be remarkably healing. Yet if a 
therapist has one eye on the patient 
and one eye on the steep climb up the 
greasy cash-and-power pole, the 
patient suffers. 

Psychiatric residents, in fact, no 
longer really learn psychotherapy. It's 
mostly Drugs "R" Us, which ensures 
minimal patient contact and a com 
fortable li\ing. It is difficult to attend 
fully to a patient while attending to 
a sexy career. Grooving on yourself 
may make it hard, c\'cn, to Primum 
non noccrc. 

The Lust for Knowing Everything 

Thankfully, the lust for omniscience 
can often be helpful to patients. But 
lust in any form narrows our vision, 
and sometimes the lust for knowing 
everything can blind doctors to mak- 
ing a good connection with a patient, 
or taking a good history, or remem 
bering that common diseases occur 
commonly and that hoofbeats out- 
side the window don't always signify 
a zebra. 

When 1 was a medical student I had 
a 55'year-old patient with shortness 
of breath. She had a terrific workup b\- 
Doctors Who Know Everything, but 
no one could figure out what ailed her. 
A lung biopsy showed eosinophilia. 
She lay there on the ward, gasping. 


diseased or 

failing, getting depressed. I spent 
hours with her, asking her about her 
Ufe. One day she mentioned that she 
rented out rooms in her house and that 
one of her tenants was a magician. 
When she told me that he kept 
pigeons for his act in cages above her 
wa.sher and dryer in the basement, my 
ears perked up. I asked questions. It 
turned out that when she ran the 
dryer, the pigeon droppings became 
aerosolized; she had been inhaling that 
dust for years. I rushed to the library 
(in those days we still used libraries 
and consulted actual books); pigeon- 
breeder's lung disease. 

The lust to make the diagnosis had 
prevented the medical redhots from 
listening deeply enough to make the 
diagnosis. In good medicine and life, 
good connection always comes first. 
Self-centered lust often creates a 
debt. Patients — or a doctor's family 
members or friends, given the time 
and effort it takes to become a Doctor 
Who Knows Everything — suffer from 
this compounded debt. 

The Lust for Sex 

When I was a third-year medical stu- 
dent I was startled to learn that the 
classic object of lust — sex — was 
rampant in teaching hospitals. I was 
on my first rotation, in surgery. One 
night I was heading for bed in the 
upper bunk when, from the lower 
bunk, the surgical resident snarled, 
"Get lost." I asked why. He nodded 
toward the nurse standing in the 
doorway. I was shocked! In the hospi- 
taU While he was on calU Call the 
Teaching Hospital Sex Police! 

Two years later during my first 
week of internship we interns (all 
male) were invited to a party hosted 
by nurses (all female but one). As I 
sat there chatting and sipping my 
wine, a nurse told me to hold out my 

hand, palm up. She placed a cork- 
screw in it, closed my hand over it, 
smiled, and asked, "Get it?" At first I 
didn't. But then I did. 

Years later I found out that most of 
the other interns did as well — even 
the married ones. Given the senseless 
pressures we faced, sex was one of the 
tw'O ways we affirmed that we weren't 
diseased or dying or dead, but rather 
young and healthy and alive. The 
other was the use of humor, pretty 
dark humor. We rode through the 
internship on sex and humor. Was it 
lust? Often, but often it was a kind of 
love, if not love itself. Sometimes it led 
to a healthy lust, a happy marriage. 

In Sonnet 129, Shakespeare writes, 
"The expense of spirit in a waste of 
shame / Is lust in action ..." But could 
the Bard have been mistaken? Was 
his take on lust too narrow, his 
shame too acute? Perhaps if the suf 
feting of the spirit is great enough, 
the expense is small. 

Missionary Lust 

Finally, a grand and good medical 
lust — the for making patients 
and the world better. This lust is not 

self-serving; it expands from .self cen- 
teredness to our patients and to oth- 
ers. The urge is broad enough to 
encompass the world of patients, and 
maybe even the world. The expense 
of spirit is for the sake of in.spiring, 
and it is an investment, not a debt. 

I recently heard a story about a doc- 
tor working in a leper hospital in Asia. 
A physician friend came to visit her 
and, seeing the conditions and her 
hardship, said, "I couldn't do what you 
do for a million dollars!" She replied, 
"Neither could I." 

One of the greatest things about the 
newer generation of doctors is this lust 
for making the world better. Their 
accomplishments before, during, and 
after medical school are astonishing. 
If that's lust, give us more! Selfless lust 
for doing good? Saintly lust? It just 
might cure the world. ■ 

Stephen Bergman 7i, PhD, as "Samuel 
Shem" is author of the novels The House 
of God, Fine, Mount Misery, and the 
upcoming The Spirit of the Place. With 
his wife. ]anet Surrey, he has coauthorcd the 
play Bill W and Dr. Bob and the hook 
We Have to Talk: Healing Dialogues 
Between Women and Men. 




percussing the ground and creating the bass 
to the treble notes struck by the chains 
Unking their legs. Perched above, an aerialist, 
decked in spangles and tights, pushed the trapeze 
into a test swing. It was 1937 and I was five years 
old, still in short pants. With my older brother, 
Bill, and my mother, I had traveled to the Boston 
Garden to see the circus — my first. The air burst 
v^th excitement and noise, and everything seemedi 
wonderfully exot«^j»ddenly, not far from us, 



an ear-splitting roar. As we stared at ro ws of large, 
scary teeth. Bill and I caught our brea 
Bill leaned toward me, his sailor hat askew. With 
a grin as toothy as the great feline's roar, he asked, 
"Who fixes the tiger when he has a toothache?" j 

Y S. Patton 


during the short hfe of the Harvard School of Veterinary Medicine. 








he Harvard School of Veterinary Medicine was . 

the fourth veterinary school in the United States I 

and the first to be organized as part of a university. 

The answer to my brother's ques- 
tion may ha\'e been the circus vet 
erinarian. Or it may have been 
Boston's Angell Memorial Animal 
Hospital, established in 1915. But 
the most likely answer, one I 
learned decades after my brother 
posed the question, was the Osgood 
Animal Hospital on the corner of 
Village and Lucas streets in the 
South End of Boston. A ruddy brick 
structure designed by famed archi- 
tect Stanford White, the Osgood 
Animal Hospital provided medical 
care not only to the four-legged 
members of many a Boston family, 
but also to large animals, including 
horses, cows, and, when the circus 
was in town, the occasional tiger 
or elephant. 

when the Osgood Animal Hospi- 
tal opened for business in 1901 it 
needed to do little by way of adver- 
tising or set up; it had inherited its 

trade, implements, building — and 
mission. The hospital had first 
thrown open its unique horseshoe- 
shaped door, one large enough to 
accommodate an elephant, nearly 
two decades earlier as part of a far- 
sighted, but ultimately ill-fated, 
effort to establish the Harvard 
School of Veterinary Medicine. 

Affiliated with Harvard Medical 
School and boasting a roster of fac- 
ulty gleaned from the Medical 
School's ranks, the School of Veteri- 
nary Medicine was the fourth vet- 
erinary school in the United States 
and the first to be organized as part 
of a university. Begun in 1882, it 
would last a mere 19 years, one of 
the rare graduate departments at 
Harvard that failed to thrive. 
Despite its brief existence, however, 
it catalyzed new thought about the 
academic preparation of veterinari- 
ans. Its rigorous course of instruc- 

tion and length of training matched 
or exceeded that found in the best 
European veterinary science insti- 
tutions of the time — and set stan- 
dards that other U.S. veterinary 
schools sought to match. 

That Old Chestnut? 

The veterinary school began as one 
man's idea and grew through anoth- 
er man's vision. The idea man was 
Charles Eliot, the luminary who 
served as president of Harvard Uni- 
versity from 1869 to 1909. The vision 
fellow, and the person whose day- to- 
day efforts made that \ision tangible, 
was Charles Parker Lyman, a respect- 
ed fellow of the Royal College of \ et- 
erinary Surgeons and the first dean 
of the veterinary school. 

During his tenure, Eliot reformed 
many of the policies and practices 
of the university, particularly at 



transformed the teaching of science at 

the university by adding new disciplines 

and reforming the teaching of existing 

ones. His insights provided the spark 

for the veterinary school. 

CharlesTWRii LyillUli, lilM UyOII Ul Hie 
Harvard veterinary school, established a 

standard-setting curriculum that was 

scientifically rigorous, had a broad scope, 

and drew upon the expertise of faculty at 

Harvard Medical School. 

Boston busineSfflBfrtenjamin Bussey 
was a silversmith, on owner of an overseas 

trade for general merchandise, and a 
founder of woolen mills. His Boston estate, 

willed to Harvard, became the Bussey 
Institute and farm. 



Harvard Medical School. Despite 
great advances in surgery, anesthc 
sia, and medicine, the School had 
become academically lax, with min 
imal requirements for admission 
and only four months of formal 
instruction per year. The education 
al program depended on an appren- 
tice system subject to favoritism 
and an inconsistent curriculum. 
Several Boston families ran the 
School like a fiefdom, and their mem- 
bers found admission easy. Final 
exams were oral, and students who 
paid their fees rarely failed to grad- 
uate. Histories of the time suggest 
that the institution bordered on 
being a diploma mill. When Eliot 
tried to make curricular changes, 
the faculty accused him and the 
members of the Harvard Corpora- 
tion of unjust interference. 

"Does Mr. Lowell know any 
thing about medical education? 
Or Reverend Putnam? Or Judge 
Bigelow?" famed surgeon Henry 
Bigelow, Class of 1837, bellowed in 
protest. "Why, Mr. Crowninshiekl 
carries a horse-chestnut in his 
pocket to ward off the ravages of 
rheumatism! Is the new medical 
education best led bv a man who 

( • 


UNLUCKY HORSESHOE: The Harvard veterinary school hospital, whose doorvt^ay 
was noted for its unusual shape, operated on a shoestring throughout its existence. 
Financial difficulties presented themselves at inception, when a requirement to guar- 
antee a sustained 6-percent net annual income could be met only vs^hen one of the 
school's first faculty members, William Whitney, provided $500 from his own pocket. 

keeps horse- chestnuts in his pock 
et to cure rheumatism?" 

Down on the Form 

Despite the howls, Eliot's reforms 
succeeded, and strong academic 

departments of anatomy, physiology, 
and chemistry emerged. Research 
received greater emphasis, and pro- 
fessional standards rose dramatical- 
ly. This growth included the estab- 
lishment of the Bussey Institute, a 
facilitv devoted to the horticultural. 


1 ;•«- 



Farm Hospital 

The Bussey Institute, located on the site 

of the current Arnold Arboretum, was 

dedicated to the study of horticulture, 

agriculture, and farming sciences. 

faculty , 

Drawn from the ranks of 
HMS, veterinary school facul 
included William Whitney (abovi 
who taught histology and parasiti. 
diseases, and J. Collins Warren (rigHtJ^ 
assistant professor of surgery. 

he Hospital 

me facility at 50 Village 

Street in Boston allowed 

Harvard veterinary students 

to gain surgical and clinical 

experience while caring 

for local animals. 




agricultural, and farming sciences. 
Founded in 1871 through a bequest 
from Benjamin Bussey, a successful 
Boston merchant, and located at 
what is now the Arnold Arboretum, 
the institute was surrounded by a 
working farm. 

With farm animals an important 
focus, the institute's programs includ- 
ed courses in veterinary medicine. 
Eliot believed that properly trained 
practitioners of veterinary science 
would contribute to the public good 
by helping to reduce costly epizootic 
diseases among cattle, horses, and 
swine, for example, and by ensuring a 
supply of healthy animals for the 
country's transportation system. 
This notion, however, was not an 
easy sell to Harvard's governing 
groups. In an 1894 address to stu- 
dents of the veterinary school, 
Charles Francis Adams, Jr., president 

of the Union Pacific Railroad and a 
trustee for Harvard Uni\ersity, noted 
that the opposition believed that 
Harvard was "committing a species 
of indignity in concerning itself in 
the care of brute creation." The deci- 
sion-makers thought educating 
physicians was fine but recoiled at 
the thought of giving diplomas to 
"horse doctors and cow doctors." 

"It is true there was high author- 
ity for, in certain contingencies, 
throwing physic to the dogs," Adams 
added, "but the objectors saw no 
sufficient reason why the University 
should do the throwing." 

But assent, howe\'er reluctant, was 
finally given and Eliot moved ahead, 
inviting Lyman, an educator and vet- 
erinarian, to the insritution. A nati\'e 
of New York City, Lyman had gradu- 
ated from the Veterinary College in 
Edinburgh, Scotland, and taught \'et- 

erinary courses at the Massachusetts 
Agricultural College. His appoint- 
ment as a professor of the Harvard 
School of N'eterinary Medicine began 
in 1882; four years later, he was made 
dean. From the first, he worked to 
build a comprehensive and rigorous 
curriculum. .An 1883-84 annual report 
of Harvard College details his ambi- 
tious program — and hints at his pride 
in the school's early accompbshments. 
The report announced that courses 
in the theory and practice of veteri- 
nary medicine and surgery, medical 
chemistry, and pathological anato- 
my were to be added, giving heft to 
the basic line-up of anatomy, physi- 
ology, chemistry, and botany. The 
additional courses also brought 
Lyman closer to building his pro- 
posed three-year course of study for 
veterinary students. The resem- 
blance of this academic litanv to that 

WATER WHEELS: Earty firefighters depended on horses to propel fire wogons wherever 
needed. The devastation v^rought by the Boston fire of 1 872 was attributed in part to 
a flu-like epidemic .among horses thiiat left many fire units v«^ithout critical horsepower. 



^^^^ ^ Ithough powerful teams of horses usually hauled the 
■ ^Jl fire carts and pumpers, on the day of the blaze almost 
^^^ ^ all these mighty beasts were disabled by disease. 

expected of medical students was 
no coincidence; Lyman aimed to 
build a curriculum heavily weighted 
with scientific subjects, mirroring 
that provided to HMS students. 

Academic growth was matched by 
clinical growth. From the autumn 
of 1883 to the following autumn, the 
school's clinics treated nearly 1,500 
patients. The 690 "in door" patients 
at the Village Street hospital includ- 
ed 476 horses, 186 dogs, 14 cats, ten 
cattle, and one squirrel. 

Among the faculty teaching the 
courses were the eminent surgeon 
J. Collins Warren, Class of 1866, assis- 
tant professor of surgery; the pioneer- 
ing physiologist Henry Bowditch, 
Class of 1868, professor of physiology; 
and the noted pathologist William 
Whitney, instructor in histology and 
parasitic diseases. 

When the school outgrew the lec- 
ture facilities at the Bussey Institute, 
not to mention the inconvenience of 
having its students travel from 
dowTitown Boston to the institute's 
rural location, Lyman oversaw the 
construction of classrooms adja- 
cent to the Village Street hospital. 
The Bussey Institute retained its 
affiliation with the hospital, howev- 
er, serving as a rest and recupera- 
tion facility for large animals that 
had been treated at the hospital. 

Horse Sense 

From its inception, the veterinary 
school emphasized the care of large 
animals, particularly the horse. In 
the mid-nineteenth century steam 
trains took over long haul work, 
but the horse was still the most 
common and efficient method of 
local transportation. By the end of 
that century, Boston was home to as 
many as 15,000 horses; an estimated 
40,000 people traveled daily in 
horse cars while another 2,500 rode 
in carriages. A horse-drawn trolley 

that ran from Harvard Square to 
Scollay Square took only 25 minutes 
and cost a nickel. 

A large industry devoted to horses 
developed. Research determined the 
amount of work that could be expect- 
ed from each breed and, to help bal- 
ance upkeep costs with productivity, 
books detailed the amount and types 
of feed most likely to produce top 
performance from each breed. Horses 
were assigned to jobs based on their 
physical attributes. Strong beasts 
powered wagons; rehable ones pulled 
carriages, taxis, sleighs, and trolleys; 
and handsome specimens trotted out 
for shows and Sunday rides. 

Some historians beheve that the 
great Boston fire of 1872 — a 35-hour 
inferno that de\oured more than 750 
buildings in central Boston — helped 
promote the establishment of the 
veterinary school. Although power 
ful teams of horses usually hauled the 
fire carts and pumpers, on the day 
of the blaze almost all these mighty 
beasts were disabled by a disease 
that resembled human influenza. 
Much of the equipment had to be 
hauled by the firemen themselves, 
slowing the response to the disaster. 

The need for more scientific care 
for horses was probably not the only 
force to support the creation of a 
veterinary school. During the nine 
teenth century a change in thinking 
about maris position in the hierarchy 
of the universe emerged. Sparked in 
Boston by the transcendentalist 
movement, new views emphasized 
the intimate connection between all 
nature and mankind and advocated 
respect for the natural world. Led by 
prominent abolitionists and Quak 
ers, a consensus emerged that the 
kind and empathic treatment of all 
life forms was an important social 
value. The de\'elopment of a rational 
and sympathetic science around 
the care of animals resulted from 
this movement. 

The School of Veterinary Medicine 
flowered in this milieu. In 1899, a 
Boston Daily Globe article about the 
Harvard veterinary hospital captured 
the relationship between the humane 
movement and the care of animals. 
"The milk of human kindness, once it 
begins to flow, is fluid that increases 
in greatly unexpected volume and 
often finds a course through totally 
unlocked for channels," the reporter 
wrote. "And so it is not strange that 
while so much was being done for 
humanity, somebody should look 
around and plan for the fullest mca 
sure of kindness to humanity's dumb 
friend and brother." 

Roonns with a View 

Firefighters, draymen, and Boston 
Brahmins all brought their animals 
to the Village Street hospital. Fees 
were kept low even though the hos- 
pital depended on its income to con- 
tinue operating; it was built largely 
through private contributions and 
never enjoyed the comfort of an 
endowment. In keeping with Eliot's 
idea that the public's health was 
served by well tended and healthy 
livestock, the daily rate for board, 
treatment, and medicine for sick 
horses was set at two dollars per 
day; surgical cases commanded half 
that fee. Dogs were boarded and 
treated for 50 cents a day and out- 
patient visits carried a charge of one 
dollar. Large animals that needed to 
stay at the Bussey Institute farms 
were treated and boarded for $4.50 
per week. 

Those who couldn't bring their 
animals to the X'illage Street hospi- 
tal could bring them to the school's 
Free Clinic on Piedmont Street dur- 
ing the two days it was open each 
w'eek. There clinicians treated thou- 
sands of ailing or injured animals, 
charging their owners only for the 
cost of medications. 



ome have postulated that the school failed 
because it was ahead of its time, created when 
'veterinary medicine commanded little prestige. 

Hospital staff — which included 
surgeons, other veterinary personnel, 
and grooms — treated animals for 
innumerable conditions, such as 
pneumonia, azoturia, locomotive 
problems, lameness, bloat, hoof and 
mouth disease, distemper, and the 
occasional toothache. Offices for the 
surgeon and assistant surgeon were 
located on the first floor; sleeping 
quarters for the on-call assistant sur- 
geon were on the third floor. 

The hospital was designed with its 
patients in mind. Apart from the sur- 
gical staff offices, most of the first 
floor was a large, open area, pa\'ed 
with asphalt, equipped with a water 
supply and hose for easy cleanups, 
and illuminated by a skylight. In addi- 
tion to providing natural light for 
surgeries, the atrium-like interior 
allowed students to watch operations 
from upper-story "galleries." Surgery 
patients were bedded dowm, especial- 
ly when the procedures were expect- 
ed to be complex, and anesthetics 
were administered according to the 
species. Large animals received ether 
or chloroform while dogs and smaller 
animals received only ether, as their 
hearts could not tolerate chloroform. 

On the first floor, se\'en stalls and 
four box stalls, plus a padded one for 
violent cases, offered accommoda- 
tions to horses. .An elevator, spacious 
enough to loft the largest patients, 
lumbered between the building's 
three levels. For ambulatory animals, 
and for evacuation in case of fire, a 
long incline stretched to the second 
floor where grooms' quarters and 
kennels for dogs and cats were locat- 
ed. This level also housed a pharmacy 
and an instrument area containing 
surgical tools such as delivery for- 
ceps, oversized stomach pumps, 
catheters, clamps used during cas- 
trations of stalhons, and tooth and 
molar forceps, the latter being 
described by one chronicler of the 
period as having "great length of 

handle, fastening upon the tooth by 
a screw, an altogether formidable- 
looking instrument." 

The hospital's third floor housed 
the hay and grain loft, the work- 
rooms, and the harness room. The 
building's basement offered stalls 
for cows and contained a black- 
smith forge; shoeing animals prop- 
erly was considered as important as 
any of the more involved treatments 
provided to patients. 

The 1899 Boston Daily Glohc article 
about the hospital described the 
dramatic saves that occurred on a 
typical day. A horse suffering tem- 
porary paralysis of his hind limbs 
was rushed to the hospital by ambu- 
lance; miraculously, he was nursed 
back to recovery. A horse with a 
fractured pelvis recovered as well, 
aided by a traction system of pulleys 
and hoists that reUeved some of the 
weight borne by the injured bones. 
A Yorkshire terrier who had been 
rescued from a house fire in "a 
scorched and senseless heap" was 
nursed back to health, and surgeons 
removed a sliver from the eye of an 
Irish terrier, a painful condition he 
had been growling about for nearly 
a year. The reporter also witnessed 
"spaniels and Maltese poodles and 
pointers and beagle hounds that had 
undergone surgical operations and 
lived to bark about it." 

To the Four Winds 

Unfortunately, although business 
was brisk at the hospital, the ^■eteri- 
nary school's general finances were 
sluggish. Yearly reports cited finan- 
cial difficulties, the lack of an endow- 
ment, and shortfalls in faculty 
salaries as chronic problems. By the 
end of the nineteenth century it was 
clear the school would need to close. 
The Free Clinic ceased operations on 
November 22, 1900, and the \'illage 
Street hospital closed on June 1, 1901. 

The school had graduated 128 stu- 
dents during its brief existence. 
Har\'ard Uni\ersit)' paid the tuition 
of the remaining students to attend 
the Uni\ersity of Pennsylvania's \'et- 
erinary department, where all but 
three transferred at the begiiming of 
the new academic year. One entered 
another \eterinary school, and two 
transferred to HMS. 

The X'illage Street hospital was 
taken over by Frederick Osgood, its 
super\ isor for years, and it operated 
as an animal hospital until 1964, 
when it was destroyed in the taking 
of land for urban renewal. 

Much speculation has arisen as 
to the precise cause of the veterinary 
school's demise. Some have postulat- 
ed that the school was ahead of its 
time, created when veterinary med- 
icine commanded little prestige 
because it was the pur\iew of nonsci- 
entific practitioners. Others have 
suggested that it came too late, that 
the power of horses was being 
replaced by the horsepower supplied 
by the combustion engine. 

Those closest to the school during 
its demise, though, cite the lack of 
endowment as the fundamental rea- 
son for its failure. In a 1900-01 report 
to the president and treasurer of Har- 
\'ard College, Lvman gentlv takes the 
readers to task for their failure to 
endow the veterinary school, point- 
ing out that similar institutions at 
the Uni\'ersity of Pennsyhania and 
Cornell had been "handsomely taken 
care of in this respect." For Harvard's 
school, he added, "hope had finally to 
be abandoned"; it could not continue 
as a "long and unaided endea\'or." 

With the shuttering of its veteri 
nary school and transfer of its animal 
hospital, Har\'ard lost forever a special 
connection with its animal friends. ■ 

Anthony S. Patton '58 is a retired thoracic 
and vascular surgeon whose career was cen- 
tered at Salem Hospital in Massachusetts. 



A Whole New Ballgame 



During its short tenure, 
the Harvard School of 
Veterinary Medicine 
could count among its 
graduates one of the 
first African Americans 
to earn a professional 
veterinary degree and 
the first dean of veteri- 
nary medicine at a 
major university. Per- 
haps most surprising, 
though, was the alum- 
nus who became the 
only undefeated foot- 
^y^^sm k- V^^^M '^'^" '^°<^'^'^ ''^ •'^^ histo- 

K ' ^^k ^f' U^^IBi ''Y °^ '^^ University 

of Nebraska. 

Henry Stockton Lewis, class of 1 889, may well have 
been the first person of African descent to earn a veteri- 
nary degree in the United States. Lewis, who also would 
prove to be a leader in the development of the veterinary 
profession in Massachusetts, originally worked in his 
father's profession: hoirdressing. In October 1885, howev- 
er, the 27-year-old barber set aside his shears and, as one 
of ten — among them a shipping clerk, a druggist, and on 
ice dealer — enrolled in Harvard's veterinary school. 

Four hard years later, degree in hand, Lewis moved to 
Chelsea, Massachusetts, where he practiced veterinary 
medicine and maintained an active presence in local and 
state politics. Lewis was appointed 
to two terms on the Massachusetts 
Board of Veterinary Registration. 
His work on this board ultimately 
helped establish it as the state enti- 
ty that defined and enforced pro- 
fessional standards for Massachu- 
setts veterinarians. 

A graduate of the class of 
1 894, Richard Pope Lyman also 
was following his father's lead. 
Son of Charles Parker Lyman, the 
first dean of the Harvard veteri- 
nary school, the younger Lyman 

became the first dean of the veterinary science division at 
Michigan Agricultural College, an institution that would 
become Michigan State University. The veterinary division 
was launched in 1910 with Lyman's arrival and followed 
a rigorous curriculum, echoing the one Lyman hod experi- 
enced at Harvard. 

During his decode-long tenure, Lyman sow to it that 
students not only were trained in animal husbandry and 
sanitation but were also prepared to "cooperate with stock 

Henry Stockton Lewis (left) 
and Richard Pope Lyman 

owners and veterinary surgeons in the investigation and 
prevention of animal ailments." These efforts recall those 
of the Harvard president, Charles Eliot, who emphasized 
how students could contribute to the public good by 
combating disease and injury in the animals people 
depended on for food and labor. 

Langdon Frothingham, class of 1 889, had one aspect to 
his career that mode it more unusual than the careers of 
many Harvard veterinary school graduates. He served 
as the first, and only undefeated, coach of what would 
become a football powerhouse: the Nebraska Cornhuskers. 

A leader in infectious disease research in animals, 
Frothingham studied tuberculosis, glanders, mycosis, and 
rabies. He codiscovered on infectious disease in cattle that 
was caused by an organism similar to the tubercle bacil- 
lus. This disease became known as Johne's Disease, an 
abbreviation of Johne and Frothingham's Disease. 

Frothingham also was a pioneer in the fields of medical 
mycology and veterinary pathology. His histologic investi- 
gation of more than a thousand rabid dogs established 
that particular nerve bundle became inflamed in infected 
animals, o practical marker for pathologists faced with 
examining dead animals suspected of carrying rabies but 
whose bodies ore partially decomposed or whose 
heads ore missing or damaged. 

Frothingham's posts took him from Nebraska to Ger- 
many and ultimately bock to Boston to serve as on instruc- 
tor in pathology in Harvard's veterinary school and as a 
professor of bacteriology and comparative pathology at 
Harvard Medical School. 

Although a pioneer in his pro- 
fession, Frothingham's brief role 
as a coach gained him a for 
broader legacy. After graduation 
from Harvard's veterinary school, 
he accepted on appointment as 
instructor at the University of 
Nebraska in Lincoln. The universi- 
ty hod been attempting to estab- 
lish the gome of football, but was 
having trouble finding someone 
knowledgeable enough in the 
sport to lead the team. Enter 
Frothingham, who, when he 
moved west, not only had carried an understanding of 
the gome, nurtured during his Harvard days, but hod 
also packed a football in his luggage. He became the 
coach of the young Nebraska team, then called the Old 
Gold Knights. The choice proved providential; his enthu- 
siasm for the gome succeeded in inspiring the team to 
victory in both games of its 1890-91 season, giving 
Frothingham on undefeated record yet to be matched 
by another of Nebraska's coaches. ■ 






jA , 

ii'' 1 »;■ 

' r -I 

« r 


\f ^'^ 





the first time can be a formidable experience for medical 
students. The technical principles they have labored 
to learn suddenly seem less powerful and less a mea- 
sure of their abilities. What they now confront is the 
challenge of developing empathy, of cultivating an 
understanding of the people they seek to aid. The essays 
collected in the recently released book The Soul of a 
Doctor chronicle this transformation among Harvard 
Medical School students as they learn to take respon- 
sibility for the health and lives of their patients — and 
to master the art of doctoring. 




hy Kim-Son Nguyen 

She looked up, her eyes weary, her mouth sour \\ith 
acidic \'omit. The dangHng nose ring again caught 
my attention. "How are you feeUng now?" I asked, 
ahnost whispering, futilely trying to respect her pri- 
vacy as she lay on a stretcher in the hallway to the 
trauma area. "Still in lots of pain," she whispered back. After 
four hours of writhing with pain and vomiting on the stretch- 
er, she had learned to give up begging to be seen by a real doc- 
tor and had resigned herself to accepting a third-year medical 
student as her only caregiver. Her female companion had fall- 
en asleep on a chair at the foot of the stretcher, oblivious to all 
the vomiting, lacerations, gunshot wounds, and two-story 
jumps occupying the emergency department at three o'clock 
in the morning. 

I ran out of things to say and patted my patient's pale, IV- 
pierced arm. She looked even younger than her age. I could 
imagine myself reporting at morning rounds: "Twenty-year- 
old female, status post-abortion three months ago, presented 
with a three-day history of diarrhea and bright red blood per 
rectum..." I wondered whether the residents at rounds would 
ever put a face to my patient. Perhaps they would never place 
a ring on that young nose. 

"Fm thirsty. Could I ha\-e something 
to drink?" she asked again, for the fourth 
or fifth time. 

"We're trying not to gi\e you any- 
thing by mouth, in case you need to go to 
the operating room." I paused. "But I 
guess you could take some ice cubes." 
The fact that, after weeks of following 
orders, I had made a decision suddenly 
seemed momentous. A strange sense of 
pride took over, until her pained face 
brought me back to reaUty. 

"Thank you," she said. 

Three o'clock. Then four. Then five. 
More abdominal -pain cases passed 
through, with a few lower-back injuries, 
one intoxication, and the usual few who 
were verbally abusive. Pains were 
mixed together; women and men, the 
young and the old, the drunks and 
the addicts, the poor and the wealthy, 
the longtime Bostonians and the been- 
here-three-weeks Haitians blended 
together into an amorphous mosaic of 
human suffering, rage, and anxiety. Fi\'e 
o'clock in the morning. Was it really 
five already? I sat down on a blood- 
stained green plastic chair in a room 
near the triage area for a quick break. 

Three weeks in the wards and almost 
three weeks in the emergency depart- 
ment had penetrated the core of my 
soul. I did not know how. I just knew 
that something inside me had been 
affected, and I was changing imisibly 
but, paradoxically, so clearly. How was I 
supposed to feel when watching an 
abdomen being cut by a No. 15 blade, 
the fascia separated by a Bo^ie set at 40 
watts, powerful enough to fill the room 
with the nauseating smell of burning 
flesh? When blood and stool from a per- 
forated small bowel o\'erwhelmed the 
suction and flooded the floor of the 
operating room? When the team 
stopped resuscitation efforts and pro- 
nounced the patient — a husband, a 

These essays were excerpted from The Soul of a Doctor: Har\'ard Medical Students Face Life and Death (AlgDnquin Books, 2006) 



mother, a child — dead? How was I 
supposed to feel when my patient 
cried with pain from broken bones, 
crushed tissue, and lost hope while 
I stood quietly by her bedside, 
equally hopeless? 

Reflection seemed impossible when 
the bombardment of emotions never 
stopped. I let everything in, perhaps 
foolishly, perhaps stubbornly Every- 
thing I had seen remained in me, hid- 
ing in my cells, penetrating my heart. 
I had thought I would cry, but to my 
surprise I did not. .Alter 24 hours at 
the emergency department, I would 
go home and sleep most of the day. 
Sleep provided the unique luxury of 
nonexistence and nonfcehng. Then I 
would awaken and return to the hos- 
pital, decei\ing myself that I was 
fresh for another day, all the while 
knowing that I would feel the burden 
of the previous day — no, that is not 
completely true. I would feel the 
experience of the previous day and 
the many days preceding it. I loved 
my time in the hospital, but I won 
dered whether emotions would 
ever overwhelm intellectual growth, 
whether tears, when they came, 
would cloud learning. 

I stood up and left that httle room. 
My nose-ring patient had finally fall 
en asleep, her stretcher still lying in 
the hallway. I walked down the 
empty corridor to the radiology 
department to have her CT images 
read. Five minutes later, I returned 
to the triage area. The stretcher was 
still there, against my faint hope. She 
was awake again, retching but not 
throwing anything up. She raised her 
head as I approached. 

"Sorry," she murmured, probably 
for appearing so sick in front of me. 
More retching. I waited, savoring 
this lull in conversation. She finally 

stopped trying to vomit and la\' back 
down on the stretcher. 

"Your CT scan shows that it's very 
unlikely you have appendicitis." 

She let out a loud sigh, even man- 
aged to flash a smile of relief. "So I 
don't have to be operated on?" 

"No," I said quietly. 

She closed her eyes for a moment. 
"I'm so happy to hear that." 

I stood there, feeling my heels 
pressing down hard on my Dansko 
clogs. The CT images were still fresh 
in my mind. The multiple masses 

were worrisome to the radiologists 
and even to my untrained eyes. Of 
course, I wasn't going to tell her 
anything else. More tests were to 
be done. No cancer yet, despite the 
masses throughout her abdomen. No 
cancer yet. 

I walked away from her stretcher. 
Suddenly I wanted to cry ■ 

Kim-Son Nguyen '07 ispursuing a master's 
degree in piihlic policy at the John F. Kennedy 
School of Government. He plans to seek a 
residency in internal medicine. 

dited hy Susan ?orics, MD, Sachin H.Jain '07, and Gordon Harper '69. 




The Saudi government had sent the H-year-old boy 
to Children's Hospital in Boston to receive the best 
medical care in the world. I had heard his story 
before starting my pediatrics rotation. He was the 
Toll receptor mutation on the eighth floor, one of a 
handful of people worldwide with this genetic defect. In fly and 
mouse models, the Toll receptor and the molecular pathway in 
which it operates are necessary for embryonic development 
and basic immune function; animals v^dth this mutation cannot 
defend against simple bacterial infections. 

How remarkable, I thought, it would be to see the manifestations 
of such a mutation in a human being. This was why I had want- 
ed to do a pediatrics rotation at the renowned hospital: to see 
zebras. Good doctors think of horses when they hear hoof beats, 
but they ne\'er forget that zebras occasionally sound those beats. 

This boy's case was a zebra's zebra. 
Some in the scientific -medical commu- 
nity view patients hke him as natural 
experiments, individuals with inborn 
genetic defects exposed to the light of 
science. A scientist can spend years 
studying a mouse that carries a muta- 
tion like his. To the medical world, 
exquisite knowledge and suffering were 
embodied in that young boy. 

On the first day of my rotation, the 
immunology fellow presented the boy's 
case. The fellow seemed enthralled, espe- 
cially when he was discussing how 
this patient was going to be studied. 
Apparently a great deal of scientific 
legwork remained, because the muta- 
tion didn't ht neatly into any classic cat 
egories. The intellectual substance was 
undeniably thrilling, yet we seemed to 
be fetishizing a rare bird rather than 
treating a sick child. 


hy Chelsea Elander 
Flanagan Bodnar 

sometimes try to attend a nearby church, but more often 
than not I am an hour late or early because I can never keep 
straight whether the services are at nine and eleven or eight 
and ten. More than once I have ended up spirituahzing with 
the Sunday Times and a double-tall latte at Starbucks rather 

than in that stone-on-the-outside, sev- 
enties-decor-on-the- inside Episcopal 
church. But on the Sunday after my first 
month of inpatient medicine, finding 
time for church seemed more important 
than ever. Even though I arrived an hour 
early, I returned after my latte to a pew 
in the back. 

This Sunday, the members of St. Paul's 
were commemorating the 30th anniver- 
sary of the Episcopal Church's decision 
to allow women into the clergy. Coffee 
hour was also going to be especially 
elaborate in celebration of the lesbian 
minister's recent marriage; the mem 
bers of the hospitality committee had 
outdone themselves on post-service 
cake, cookies, and punch. 

During this service, church members 
were given the chance to offer indi\1dual 
prayers for healing. After communion — 
which was received in a perpetually 




hy Hao Zhu 

Se\'eral days later, while on call, I had 
an opportunity to see the boy. One of the 
female doctors knocked on the door to 
give the mother time to don her veil. As 
we put on our own gowns and masks, 
the intern mused aloud for a moment 
about what he would say if the mother 
asked what was going to happen. He 
asked the senior resident for advice, 
but she had none; there was no real ther- 
apeutic plan. Without having come up 
with a good script, we knocked again 
and walked into the room. 

It was late at night, and with the 
blinds drawn, the room had taken on a 
ghostly atmosphere. The boy's mother 
looked at us through the sliver of her 
veil. There was no telling what her face 
was expressing, much less what she 
looked like. I could only guess whether 
she was hopeful or upset or resigned, 
given their six-week stay with no opti 

mistic or even clear endpoint. The 
patient's little brother also was there, 
smiling and grabbing his mother's leg, 
conspicuous in his normalcy. 

The mother approached us like many 
patients' parents do: as if the arrival of 
the doctors would somehow help her 
son. The way she moved toward us 
showed she stUl harbored hope. But 
when I looked at the boy, I could tell 
he had little time left and that keeping 
him comfortable was the only medicine 
still available. 

He was tiny, barely three feet long, and 
cocooned in a fetal position. A machine 
blew air in and out of his chest. He didn't 
seem to be in pain, though it seemed as if 
his .soul, a full human soul, was suffocat 
ing in a congested, ravaged body. He 
didn't speak; he may have been too sick, 
or he may simply not ha\'e understood 
any English. But I was glad we couldn't 

tafk to liiin. If I had been in his place, I 
wouldn't have wanted to talk to anyone. 
I would be wondering why the doctors 
were keeping me alive. What the hell 
was all this — the doctors, the examina- 
tions, the endless blood draws? It must 
have seemed like a sick game to him. I 
wondered what was going through his 
mind as his eyes met ours. 1 hoped it was 
nothing at all, only numbness. 

As I took in the child's misery, the 
intellectual excitement I had felt 
drained away. It was a stark and uncom- 
fortable realization. He was both a gift 
and a curse to medicine: A gift because 
we could learn about his missing gene 
and its role in immunity. A curse 
because his suffering was as terrible as 
his mutation. ■ 

Hao Zhu V5 is an internal medicine resident at 
the University of California at San Francisco. 

forming and dissoKing circle around the 
front of the sanctuary — if you stay stand- 
ing, the special healing- prayer crew v\ill 
approach you ready to lay on hands and 
anoint you wth oil. I had never consid- 
ered remaining up there for even a second 
longer than necessary. I preferred my 
obser\'er status in the back of the church. 

But today, for some reason, that oh so- 
pubhc standing for a httle extra heaUng 
seemed like not such a bad idea. As the 
front of the room rose to start the wind- 
ing and unwinding communion circle, I 
wondered why I heard the offer for heal 
ing so differently this week. I wasn't sick. 
No one around me was sick. I was elated 
to be starting a much calmer month. I had 
just read the paper while drinking coffee 
for the first time in weeks. 

Then they came clearly into my mind: 
Ms. Huntington, Ms. Mission, Roseann, 
the first patients with whom I had sat as 

each heard terrible news or waited in the 
terror of not knowing or gasped their 
final breaths in that huge ho,spital. As my 
turn to rise and circle for communion got 
closer, tears came to my eyes, and I knew 
that despite all the latte drinking, I was 
still in need of help in bringing this 
month to a peaceful close. Perhaps, I 
thought, I was drawn to standing in front 
of the whole congregation with the 
prayer- for- healing team because I now 
knew real patients for whom I could pray 
for healing. But in as much time as it took 
for the row in front of my own to rise and 
begin their ambling journey to commu- 
nion, I knew the need for healing was 
also, and most immediately, my own. 

So I stood up there with the commu 
nion circle dissolving around me. It took 
only a few moments of my standing there 
alone for them to see me. Maybe they 
knew I sat in the back and rarely went to 

coffee hour, but the two women — one 
young, with a dyed white streak in her 
dark hair, and the other older, larger, in 
an orange scarf — approached. The young 
one put her hand on my head; the older 
one came with the oil. They asked for 
whom the prayer was to be prayed. I 
smiled as I found myself stumbling to say 
that it was for me, and for the whole team, 
really — probably meaning everyone from 
the team that listens to mc at night, to the 
team that really had the responsibility for 
the patients I'd seen this month. The 
healing-prayer crew was thrown only for 
an instant before they proceeded with 
earnest prayers for this mysterious whole 
team and me. I returned to my seat in the 
back pew. I felt siUy. I felt better. ■ 

Chelsea Blander Flanagan Bodnar '06 will 
undertake her pediatrics residencv at the Univer 
sity of Washington Affiliated Hospitals in Seattle. 


























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